Scholarly Work - Nursing

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    Development of the Blackfeet Community Hospice Project: Pilot Workshop
    (SAGE Publications, 2022-08) Colclogh, Yoshiko; Brown, Gary M.
    Taboo perception on talking about death and dying among American Indians/Alaska Natives is prevalent. This suppressive value makes hospice introduction difficult, leading hospice disparity. Working together by using a community-based participatory research approach over a decade, we conducted a 6-hour workshop including information sharing and group activities. The purpose of the study was to investigate the community readiness for end-of-life knowledge by conducting a public workshop. We used pre- and post-workshop surveys with Likert-type responses to five questions to assess the effect of workshop in end-of-life knowledge. Thirty individuals participated the workshop; 80% of them reported their knowledge increase on at least one question. While the survey had concerns, positive participant responses indicated readiness and appropriateness to use workshops to increase end-of-life knowledge.
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    Nursing and midwifery research priorities for Kenya: Results from a national Delphi survey
    (Wiley, 2023-10) Albanus, Albanus; Wager, Miriam; Nzengya, Daniel; Edwards, Joan; Secor‐Turner, Molly
    Background. The International Council of Nurses and the World Health Organization have prioritized evidence-based nursing and midwifery practice derived from nurse-led research. However, in a low-resource country like Kenya, there is a need to identify research priorities to optimize utilization of limited existing research infrastructure and funding. Kenya lacks a nursing and midwifery research strategy to guide research prioritization. Introduction. The goal of this study was to identify and describe nursing and midwifery research priorities for Kenya. Methods. A cross-sectional Delphi survey using two iterative rounds of electronic data collection was used to reach a consensus about priorities for nursing and midwifery research in Kenya. NVivo-12 was used to analyze the qualitative data to identify categories, sub-themes, and themes; descriptive statistics were used to analyze quantitative data. Results. Participants included 159 nurse managers, administrators, and educators representing regional, county, and national referral, private, and faith-based hospitals, nurse training schools, research institutions, and nursing organizations in Kenya. Staffing challenges, motivation, remuneration, and funding for higher education were ranked as the top critically important issues using a cutoff point of ≥ 70% agreement. Conclusion. There is a need for the development of a National Framework for Nursing and Midwifery Research Priorities in Kenya to guide research that builds excellence in meeting nursing and midwifery human resource concerns and ultimately improves patient care practices and outcomes. Implications for nursing and nursing policy. The objective of Kenya's health goals delineated within three key national health documents cannot be attained without adequate numbers of nursing and midwifery professionals and policies that address nursing and midwifery staffing challenges, remuneration for employment, and improved funding for higher education.
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    Hematoloechus sp. attachment shifts endothelium in vivo from pro- to anti-inflammatory profile in Rana pipiens: evidence from systemic and capillary physiology
    (American Physiological Society, 2023-08) Williams, Donna A.; Flood, Mary H.
    This prospective, descriptive study focused on lung flukes (Hematoloechus sp., H) and their impact on systemic and individual capillary variables measured in pithed Rana pipiens, a long-standing model for studies of capillary physiology. Three groups were identified based on Hematoloechus attachment: no Hematoloechus (No H), Hematoloechus not attached (H Not Att), and Hematoloechus attached (H Att). Among 38 descriptive, cardiovascular, and immunological variables, 18 changed significantly with H. Symptoms of H included weight loss, elevated immune cells, heart rate variability, faster coagulation, lower hematocrit, and fluid accumulation. Important capillary function discoveries included median baselines for hydraulic conductivity (Lp) of 7.0 (No H), 12.4 (H Not Att), and 4.2 (H Att) × 10−7 cm·s−1·cmH2O−1 (P < 0.0001) plus seasonal adaptation of sigma delta pi [σ(πc–πi), P = 0.03]. Pro- and anti-inflammatory phases were revealed for Lp and plasma nitrite/nitrate concentration ([NOx]) in both H Not Att and H Att, whereas capillary wall tensile strength increased in the H Att. H attachment was advantageous for the host due to lower edema and for the parasite via a sustained food source illustrating an excellent example of natural symbiosis. However, H attachment also resulted in host weight loss: in time, a conundrum for the highly dependent parasite. The study increases overall knowledge of Rana pipiens by revealing intriguing effects of H and previously unknown, naturally occurring seasonal changes in many variables. The data improve Rana pipiens as a general scientific and capillary physiology model. Diseases of inflammation and stroke are among the clinical applications.
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    Using the social ecological model to identify challenges facing Latino immigrants
    (Wiley, 2023-05) Moyce, Sally; Comey, Danika; Anderson, Jacey; Creitz, Adam; Hines, Deborah; Metcalf, Madeline
    Background. New Latino immigrant populations face challenges and barriers when arriving in new immigrant destinations. Objective. To better understand the challenges faced by Latino immigrants in a new immigrant destination by using the Social Ecological Model. Design. This study solicited the perceptions of key informants and Latino immigrant participants through qualitative data collection methods to understand how to address and decrease barriers to healthcare services and community resources. Sample. Researchers conducted semi-structured interviews with two groups of respondents: 13 key informants and 30 Latino immigrants. Measurements. Data were analyzed using thematic analysis and categorized based on the Social Ecological Model. Results. Themes identified at the individual and interpersonal levels of the Social Ecological Model include fear of deportation and stress. Themes at the community level include cultural differences, discrimination, and a lack of exposure of the majority community to Latino immigrants. At the system level, researchers identified language barriers, the cost of healthcare, and housing. At the policy level, researchers identified legal status and occupational exploitation as challenges for this community. Conclusion. Understanding the challenges faced by Latino immigrants requires multi-level interventions to address barriers that prevent new immigrants from accessing community resources.
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    Nurses’ and midwives’ participation and utilization of health-related research in Kenya: Implications for evidence-based practice
    (Elsevier BV, 2023-04) Nzengya, Daniel M.; Mutisya, Albanus K.; Wagoro, Miriam C.A.; Secor-Turner, Molly; Edwards, Joan
    Objective. To assess the level of participation of nurses and midwives in health-related research, determine the status of utilization of research to inform nursing and midwifery practice in Kenya, and explore perspectives of nurses and midwives about strategies to empower nurses/midwives to engage in health research in Kenya. Methods. Data were extracted from online survey responses of 156 nurse and midwife educators, practitioners, and managers/administrators. SPSS version 26 was used to analyze quantitative data; qualitative data were analyzed using Excel to organize data into categories. Results. Over one-third of participants reported ever publishing research (37.2%, 58/156). Participants reported using knowledge gained in nursing school to guide practice most frequently (n = 148). Utilization of research findings to guide practice was reported by 80.3% (110/137) of participants. Strategies to enhance participation in the research included research training, research forums, policy reforms, and emphasis on research in curricula. Conclusions. There is need to intensify and prioritize proposed strategies to empower nurses/midwives to engage in health research.
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    Marriage, Children, and Sex-Based Differences in Physician Hours and Income
    (American Medical Association, 2023-03) Skinner, Lucy; Yates, Max; Auerbach, David I.; Buerhaus, Peter I.; Staiger, Douglas O.
    Importance. A better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities. Objective. To investigate differences in earnings and hours worked for male and female physicians at various ages and family status. Design, Setting, and Participants. This retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019. Exposures. Earned income and work hours. Main Outcomes and Measures. Outcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022.Results. The sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children. Conclusions and Relevance. In this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.
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    Improving Early Childhood Caries for American Indian 3- to 5-Year-Old Children Through Interprofessional Outreach: 2018–2022
    (American Public Health Association, 2023-02) Larsson, Laura S.; Hodgson, Christine
    We sought to determine the effectiveness of an interprofessional health team in improving access to oral health care among American Indian children enrolled in Head Start. Our team provided preventive treatments and case management during 11 visits from 2018 to 2022. Case management reduced the time between referral and dental treatment from a median of 166 days to 58.3 days over four years. An interprofessional team is an effective way to improve access to oral health care among rural American Indian Head Start children. (Am J Public Health. Published online ahead of print February 2, 2023:e1–e4. https://doi.org/10.2105/AJPH.2022.307205 )
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    Developing a Preclinical Nurse-Nurse Communication Framework for Clinical Trial Patient-Related Safety Information
    (Ovid Technologies, 2022-11) Johnson, Elizabeth A.; Rainbow, Jessica G.; Reed, Pamela G.; Gephart, Sheila M.; Carrington, Jane M.
    Clinical trial trials have become increasingly complex in their design and implementation. Investigational safety profiles are not easily accessed by clinical nurses and providers when trial participants present for clinical care, such as in emergency or urgent care. Wearable devices are now commonly used as bridging technologies to obtain participant data and house investigational product safety information. Clinical nurse identification and communication of safety information are critical to dissuade adverse events, patient injury, and trial withdrawal, which may occur when clinical care is misaligned to a research protocol. Based on a feasibility study and follow-up wearable device prototype study, this preclinical nurse-nurse communication framework guides clinical nurse verbal and nonverbal communication of safety-related trial information to direct patient care activities in the clinical setting. Communication and information theories are incorporated with Carrington's Nurse-to-Nurse Communication Framework to encompass key components of a clinical nurse's management of a trial participant safety event when a clinical trial wearable device is encountered during initial assessment. Use of the preclinical nurse-nurse communication framework may support clinical nurse awareness of trial-related wearable devices. The framework may further emphasize the importance of engaging with research nurses, patients, and caregivers to acquire trial safety details impacting clinical care decision-making.
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    Clinical Nurses' Identification of a Wearable Universal Serial Bus Used for Pediatric Oncology Clinical Trial Participant Safety Management
    (Wolters Kluwer Health, 2023-01) Johnson, Elizabeth A.; Rainbow, Jessica G.; Carrington, Jane M.
    The expanded access to clinical trials has provided more patients the opportunity to participate in novel therapeutics research. There is an increased likelihood of a patient, as a pediatric oncology clinical trial participant, to present for clinical care outside the research site, such as at an emergency room or urgent care center. A novel wearable universal serial bus device is a proposed technology to bridge potential communication gaps, pertaining to critical information such as side effects and permitted therapies, between research teams and clinical teams where investigational agents may be contraindicated to standard treatments. Fifty-five emergency and urgent care nurses across the United States were presented, via online survey without priming to the context of clinical trials or the device, a picture of a pediatric patient wearing the novel wearable device prompted to identify significant, environmental cues important for patient care. Of the 40 nurses observing the patient photo, three identified the wearable device within Situational Awareness Global Assessment Tool formatted narrative response fields. Analysis of the narrative nurse-participant responses of significant clinical findings upon initial assessment of the pediatric patient photo is described, as well as the implications for subsequent prototyping of the novel universal serial bus prototype.
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    An overview and policy implications of national nurse identifier systems: A call for unity and integration
    (Elsevier BV, 2023-01) Chan, Garrett K.; Cummins, Mollie R.; Taylor, Cheryl S.; Rambur, Betty; Auerbach, David I.; Meadows-Oliver, Mikki; Cooke, Cindy; Turek, Emily A.; Pittman, Patricia (Polly)
    There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses’ collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers– the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.
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    Development of the Blackfeet Community Hospice Project: Pilot Workshop
    (SAGE Publications, 2022-08) Colclough, Yoshiko; Brown, Gary M
    Taboo perception on talking about death and dying among American Indians/Alaska Natives is prevalent. This suppressive value makes hospice introduction difficult, leading hospice disparity. Working together by using a community-based participatory research approach over a decade, we conducted a 6-hour workshop including information sharing and group activities. The purpose of the study was to investigate the community readiness for end-of-life knowledge by conducting a public workshop. We used pre- and post-workshop surveys with Likert-type responses to five questions to assess the effect of workshop in end-of-life knowledge. Thirty individuals participated the workshop; 80% of them reported their knowledge increase on at least one question. While the survey had concerns, positive participant responses indicated readiness and appropriateness to use workshops to increase end-of-life knowledge.
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    Trouble for trials - The worrying state of the research nurse workforce
    (Elsevier BV, 2022-09) Johnson, Elizabeth A.
    Clinical research nurses (CRNs) are a specialty of Registered Nurses that are highly trained to support the breadth of clinical trial operations and manage participant care in community settings new to research. CRNs are uniquely equipped with a scope of practice that permits product administration, participant assessments, and data management. As clinical trials and their management expand beyond traditional, site-based operations models to decentralized or remote models, the need becomes great to ensure adequate staffing of experienced research professionals, such as CRNs. However, the 2020 National Nursing Workforce Survey reported consecutive contractions in the number of CRNs practicing in the U.S in both 2017 and 2020 surveys when compared to previous reports in 2013 and 2015. The Society of Clinical Research Associates 2020 Salary Survey further described much of the current CRN workforce as nearing or at retirement age, raising concern for additional reductions. This workforce contraction tangents one of the highest volumes of clinical trial starts in modern history, prompting concern for adequate staffing of CRNs to facilitate continued examination of novel therapies and devices. Complex investigative products and evolving safety profiles coupled with an increased focus on community participant enrollment requires CRN involvement in heightened safety monitoring and interdisciplinary communication among clinical providers and research collaborators. This paper examines the contributory factors of the CRN workforce contraction and response efforts at professional and organizational system levels.
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    Treating Persistent Pain: A Nurse Co-Led, Interdisciplinary Model for Primary Care
    (Elsevier BV, 2022-07) Benes, Lindsay L.; Keefe, Frank J.; DeBar, Lynn L.
    The public health crisis of chronic pain has only increased in recognition since the Institute of Medicine's (IOM) Relieving Pain in America (2011) called for a cultural transformation in the way pain is viewed, treated, and put forward specific recommendations for action. The National Pain Strategy (NPS) provides a roadmap for putting these recommendations into practice. We implemented a program that placed nurses and behavioral specialists at the head of an interdisciplinary team utilizing best practices. In this program, nurses enacted the NPS recommendations to advance care for patients with persistent pain on long-term opioid treatment. This program promoted professional growth in nurses along with fostering success for patients. Compared with patients receiving usual care, patients in the program achieved greater reductions in pain severity, pain-related disability, and pain-related functional interference and reported greater satisfaction with pain-related care and primary care services. This article will detail the NPS-aligned practice approaches these nurses and their teams used, describe the training for the nurses, and speak to opportunities to enhance the nurse's capacity for this role in hopes of providing a model for the future implementation of an NPS-based approach by nurses.
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    Gathering Health Perspectives of the Justice Involved: A Multisite Needs Assessment Survey
    (Mary Ann Liebert Inc, 2022-08) Diller, Elena; Kouame, Gail; Young, David M.; Johnson, J. Aaron
    The well-being of justice-involved individuals must be of high priority to achieve health equity, reduce health disparities, and improve community health. To better understand the health interests and needs of justice-involved individuals, a survey was administered inquiring about health information-seeking behavior and health topics of interest. The survey was administered using secure tablet computers and completed by 1,888 incarcerated participants in 35 jails in 17 states. Salient themes that emerged from this research include the relatively equal use of the internet and health care providers as resources for health information; the extensive interest in learning about multiple health care topics; and demographic variations in health information-seeking behaviors and health topics of interest. Tailoring correctional health education programs to coincide with the interests and needs of the justice-involved population may attract more participants and thus result in better self-care management skills and health outcomes upon reentering communities.
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    Revisiting the nursing metaparadigm: Acknowledging technology as foundational to progressing nursing knowledge
    (Wiley, 2022-06) Johnson, Elizabeth A.; Carrington, Jane M.
    The nursing metaparadigm, as described by Fawcett in 1984, includes human, health, nursing, and the environment, all of which support theory development by giving direction to our focus as a scientific body. Nursing scientists make their mark in biotechnological applications, mobile health, informatics, and human factors research. We give voice to the patient through design feedback and incorporating technological advancements in our evolving nursing knowledge; however, we have not formally acknowledged technology in our metaparadigm. To continue patient-centered care in this age where machines are enmeshed in daily human life, we propose technology must be a domain of the metaparadigm to continue advancing nursing science and knowledge. In this paper, we propose a separate domain of technology within the metaparadigm to challenge nurses to consider approaches within their research and practice of how technology will impact patient care and their personal development within the profession. A technology-specific domain within the metaparadigm also is a signal to other bodies of science of our willingness and ability to run at pace with novel, exciting new discoveries while adding our perspective. Nurses may become active agents in novel developments rather than passive adopters, continuing our legacy of patient advocacy through new knowledge generation. Emerging and continuing nurse leadership has set the stage for the next era of nurse-led innovation and technology development, which provides an opportunity to embed technology as a core aspect of the nursing metaparadigm.
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    Revisiting the nursing metaparadigm: Acknowledging technology as foundational to progressing nursing knowledge
    (Wiley, 2022-06) Johnson, Elizabeth A.; Carrington, Jane M.
    The nursing metaparadigm, as described by Fawcett in 1984, includes human, health, nursing, and the environment, all of which support theory development by giving direction to our focus as a scientific body. Nursing scientists make their mark in biotechnological applications, mobile health, informatics, and human factors research. We give voice to the patient through design feedback and incorporating technological advancements in our evolving nursing knowledge; however, we have not formally acknowledged technology in our metaparadigm. To continue patient-centered care in this age where machines are enmeshed in daily human life, we propose technology must be a domain of the metaparadigm to continue advancing nursing science and knowledge. In this paper, we propose a separate domain of technology within the metaparadigm to challenge nurses to consider approaches within their research and practice of how technology will impact patient care and their personal development within the profession. A technology-specific domain within the metaparadigm also is a signal to other bodies of science of our willingness and ability to run at pace with novel, exciting new discoveries while adding our perspective. Nurses may become active agents in novel developments rather than passive adopters, continuing our legacy of patient advocacy through new knowledge generation. Emerging and continuing nurse leadership has set the stage for the next era of nurse-led innovation and technology development, which provides an opportunity to embed technology as a core aspect of the nursing metaparadigm.
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    The Caring for Our Own Program A Model for American Indian and Alaska Native Nursing Students to Practice, Manage, and Lead in Indian Country
    (Ovid Technologies, 2022-02) Larsson, Laura; Johnson, Catherine M.
    Background: Research has identified workforce diversification as influential in improving health outcomes. The Caring for Our Own Program (CO-OP) set out to achieve classroom and workforce parity for rural Native American nurses and communities. Purpose: In this study, we report quantitative results of the first 20 years of the CO-OP and explore the extent to which the CO-OP model influenced degree completion for Native American students. Approach: The CO-OP employs a 4-pillar program model where sense of place, financial security, academic readiness, and social connection empower students as they progress. One hundred twenty-one Native American students have earned nursing degrees since inception. In addition, more than 10% of CO-OP undergraduates have returned to become nurse practitioners. Conclusions: The CO-OP model replicated elsewhere may also succeed by adapting key concepts in that context to achieve health equity.
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    Engaging Latinos in an Academic-Community Partnership in Montana through a Health Screening Event
    (Informa UK Limited, 2021-03) Moyce, Sally C.; Sisson, Nathaniel; Thompson, Sophia; Velazqueaz, Maria; Claudio, David; Aghbashian, Elizabeth; Demorest, Heather; Vanderwood, Karl
    Background: Engaging minorities in research especially in Montana where Latinos make up a small percentage of the population can be a challenge. We describe an effort to recruit Latinos into a research study by hosting a health screening event. Purpose: This event served as the first step in the creation of an academic-community partnership. Methods: We formed an interdisciplinary research team and involved key community stakeholders in planning a health screening event. We provided lunch, flu vaccinations, and screening measures including blood pressure, body mass index, and diabetes status. We also asked for volunteers to sign up to participate in future focus groups. Results: Thirty five people participated in the health screening event, and 29 people volunteered to engage in future research. The majority of participants reported not having health insurance or a regular medical provider, were overweight or obese, and did not have diabetes. Discussion: Engaging the Latino community in research is important, and this paper describes the first step in the creation of an academic-community partnership. Translation to Health Education Practice: Attention to community needs through active partnership and adherence to the responsibilities and competencies for health education specialists provides an example of a successful study that can be adapted to other populations.
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    Rural Hispanic Perceptions of Mental Health: A Qualitative Study
    (SAGE Publications, 2022-01) Moyce, Sally; Thompson, Sophia; Metcalf, Madeline; Velazquez, Maria; Aghbashian, Elizabeth; Sisson, Nathaniel; Claudio, David
    Introduction: In 2020, 18.4% of Hispanics experienced mental illness, yet only about a third received treatment compared with nearly half of non-Hispanic Whites. In Montana, where only 11% of the mental health needs are currently met, service utilization is low. The purpose of this study was to determine the perceptions of the Hispanic immigrant population in a rural state on mental health and professional service utilization. Methods: Using a descriptive phenomenological approach, we conducted semi-structured telephone interviews in Spanish. Audio recordings were transcribed, translated to English, and analyzed for themes. Results: We recruited a sample of 14 participants from Mexico, Ecuador, Colombia, and Venezuela ranging in age from 33 to 59. We identified five themes: definitions of mental health, maintaining mental health, familismo/socialization, stigma, and acculturation stress. Discussion: Novel findings point to the need for Spanish-language services focused on reducing stigma around mental illness and incorporating the importance of social connections.
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    Be Wise: A complementary and alternative medicine health literacy skill-building programme
    (SAGE Publications, 2021-04) Weinert, Clarann; Nichols, Elizabeth; Shreffler-Grant, Jean
    Background: Health literacy has been found to be the strongest predictor of health status; and without adequate health literacy, consumers may not understand/adequately evaluate the myriad of choices available. Older rural residents tend to use self-prescribed complementary and alternative medicine (CAM) therapies and glean information about these therapies primarily by word of mouth/media. Objectives: The purpose of this article is to describe the Be Wise health literacy skill building programme and the participants’ evaluation of the programme. Design: The programme involved four sessions delivered over 7 weeks at seniors’ centres in rural communities. Method: Data were collected initially (N = 127), at the end of the sessions (N = 67) and after 5 months (N = 52). Setting: Participants were primarily rural Caucasian women, mean age 76 years, and most had an associate/baccalaureate degree. Results: Questions were worded to ascertain satisfaction with the programme, usefulness of the information provided, willingness to recommend the programme, and the likelihood of using the programme. All scores were most favourable ranging from 3.35 to 4.41 on a 5-point scale. A question regarding the usefulness of the Be Wise programme in managing health received at mean score of 3.55 on a 5-point scale. Written comments on the questionnaires were overwhelmingly favourable. Conclusion: Delivering programmes to older adults in small rural communities has special challenges and rewards. Participants were enthusiastic about learning more about making informed health care choices. There is a compelling need for continued programme development and long-term outcomes evaluation.
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