Conceptualizing vulnerable populations health-related research

Staying isolated indoors means that nobody sees me": ontological (in)security and living with significant appearance concerns before, during, and 'since' COVID-19

PURPOSE

Though a worldwide period of uncertainty (COVID-19) has 'ended', there exists a legacy of maladaptive experiences among people with significant appearance concerns (SAC) that requires care and attention.

METHODS

Using Giddens' concept of ontological security, we explored how people experienced their SAC before, during and "since" COVID-19. Qualitative surveys allowed us to capture diverse perspectives from individuals transnationally, analysed with deductive reflexive thematic analysis using ontological security as our theoretical foundation.

RESULTS

Themes named "More Mirror(ed) Time" and "Locked Out, Shut Down, and Shut Out" gave a contextual grounding for the embodied experiences of this group through times of social restrictions, and the theme "Redefining Relevance" explored the continued legacy of COVID-19 - and continued global uncertainties such as economic hardship and warfare - that impact the wellbeing of people with SAC.

CONCLUSIONS

People with SAC are still 'locked out' from essential healthcare support as those providing healthcare are overworked, under-resourced and rely on efficient interactive methods such as tele-health that may be triggers for people with SAC. Care providers may consider expanding appearance concerns verbiage, look to involve trusted others in the care-seeking process, and utilize modalities beyond digital health to support people with SAC.

Social capital and health beliefs: Exploring the effect of bridging and bonding social capital on health locus of control among women in Dhaka

This cross-sectional study examined if social capital affects women's health attributions. The study used the Internet Social Capital Scale (ISCS) and Multidimensional Health Locus of Control (MHLC) Scale to measure Social Capital and Health Locus of Control. A predefined 38-item questionnaire was used to survey 485 purposively selected women. A bidirectional reciprocal structural equation model was used to measure the covariance between Social Capital and Health Locus of Control. We hypothesized that women with strong social capital, particularly those rich in bridging ties, would exhibit a greater sense of agency and empowerment over their health, attributing their health outcomes less to internal factors like fate and more to external influences like powerful others and broader social support. However, we found that when women have higher social capital, their external health locus of control increases. Bridging and bonding social capital lower women's internal health control, but bridging social capital leads to higher attributes to powerful others. Likewise, we expected women with more social capital would exhibit a lower perception of uncontrollability over their health, but is not the case. The findings underscore the necessity for women to have more social capital.

Barriers to Accessing Paid Parental Leave Among Birthing Parents With Perinatal Health Complications: A Multiple-Methods Study

INTRODUCTION

Even in the small number of U.S. states with paid parental leave (PPL) programs, studies have found awareness of PPL remains low and unevenly distributed among parents. Moreover, little is known about whether parents with perinatal health complications have unmet needs in obtaining information about and support for accessing parental leave during that time. This study aims to address this research gap. Given the strong evidence linking paid leave with improvements in maternal and infant health, it is critical to evaluate access among vulnerable populations.

METHODS

We used a multiple methods approach, including a subset of the 2016-2017 Bay Area Parental Leave Survey of Mothers (analytic sample = 1,007) and interview data from mothers who stayed at a neonatal intensive care unit in 2019 (n = 7). All participants resided at that time in California, a state that offers PPL. The independent variable for the survey analysis was a composite measure of perinatal complications, quantified as binary with a value of 1 if respondents reported experiencing any of the four complications: poor maternal mental health during or after pregnancy, premature birth, or poor infant health. Dependent variables for the survey analysis measured lack of support or information for accessing PPL. We used linear probability models to assess the relationship between perinatal complications and PPL support. Thematic analysis was conducted with the interview data to understand how perinatal complications shape the process of accessing PPL.

RESULTS

Survey results revealed that parents with perinatal complications had a lower understanding of PPL benefits and low overall support for accessing leave, including from employers, compared with parents without perinatal complications. From interviews, we learned that perinatal complications present unique challenges to parents navigating PPL. There were multiple entities involved in managing leave and providing information such as the benefits coordinator and employers. Supervisors were reported as providers of critical emotional and financial support.

CONCLUSIONS

Taken together, the findings from surveys and interviews suggest that health care and human resources personnel should be better equipped to provide information and support, particularly to those who experience perinatal complications and might struggle to complete paperwork while facing health challenges.

The mechanisms of nature-based therapy on depression, anxiety, stress, and life satisfaction: examining mindfulness in a two-wave mediation model

Background

Nature-based therapy (NBT), which centers around engaging in activities within natural surroundings, has consistently demonstrated therapeutic benefits for mental health. While NBT highlights the potential of nature as a therapeutic resource for promoting mental health, there is limited knowledge regarding its underlying mechanisms.

Methods

Two hundred seventy-six Korean participants (204 women, mean age = 54.99 ± 23.25 years) participated in a 30-session gardening program held twice weekly for 15 weeks. Structural equation modeling with a two-wave autoregressive cross-lagged model was used to investigate the mediating effects of mindfulness.

Results

NBT significantly improved the mean scores of all psychological variables. The mediation model was partially confirmed, with mindfulness at post-intervention (T2) mediating the relationship between baseline (T1) depression and anxiety and post-intervention (T2) life satisfaction. However, no significant indirect effect was observed between the path from stress (T1) to life satisfaction (T2).

Conclusion

Mindfulness is a crucial component for improving mental health outcomes. This study underscores the need to prioritize and emphasize mindfulness practices in NBT.

Using Geographic Information Systems in health disparities research: Access to care considerations

In health disparities research, Geographic Information Systems (GIS) provide nurse researchers with powerful tools to incorporate spatial factors, such as access to care and related attributes like socioeconomic and environmental characteristics, into their studies. This article educates nurse scientists about GIS-based research benefits and considerations (focusing on access-to-care factors) and the influence of various access-to-care metrics on research outcomes. We present an overview of GIS in nursing and health disparities research, along with findings from our 2022 study examining access to care's relationship with county-level mortality rates in Tennessee, especially in areas where rural hospitals closed between 2010 and 2019. We highlight three distinct access-to-care measures (Euclidean distances and road network-based travel times based on county and census tract centroids), showcasing how different calculations impact our modeling results. Our results underscore the importance of understanding the choice of access-to-care metrics in GIS-based research to draw valid conclusions.

Mental Health Impacts of Climate Change Among Vulnerable Populations Globally: An Integrative Review

Background

Climate change has been shown to be directly linked to multiple physiological sequelae and to impact health consequences. However, the impact of climate change on mental health globally, particularly among vulnerable populations, is less well understood.

Objective

To explore the mental health impacts of climate change in vulnerable populations globally.

Methods

We performed an integrative literature review to identify published articles that addressed the research question: What are the mental health impacts of climate change among vulnerable populations globally? The Vulnerable Populations Conceptual Model served as a theoretical model during the review process and data synthesis.

Findings/Results

One hundred and four articles were selected for inclusion in this review after a comprehensive review of 1828 manuscripts. Articles were diverse in scope and populations addressed. Land-vulnerable persons (either due to occupation or geographic location), Indigenous persons, children, older adults, and climate migrants were among the vulnerable populations whose mental health was most impacted by climate change. The most prevalent mental health responses to climate change included solastalgia, suicidality, depression, anxiety/eco-anxiety, PTSD, substance use, insomnia, and behavioral disturbance.

Conclusions

Mental health professionals including physicians, nurses, physician assistants and other healthcare providers have the opportunity to mitigate the mental health impacts of climate change among vulnerable populations through assessment, preventative education and care. An inclusive and trauma-informed response to climate-related disasters, use of validated measures of mental health, and a long-term therapeutic relationship that extends beyond the immediate consequences of climate change-related events are approaches to successful mental health care in a climate-changing world.

Cumulative health disadvantages: an empirical study of the health and mobility of the first cohort of migrant workers in China

Background

The study aimed to understand the factors affecting the health and healthcare of the first cohort of migrant workers in China using the concept of the cumulative disadvantage framework.

Methods

Data from the China Migrants Dynamic Survey (2017) were used to analyze the process of cumulative disadvantage of health and healthcare among migrant workers. The study also analyzed the spatial lag problem between localized medical insurance policies and healthcare accessibility.

Results

The results revealed a significant negative association between the mobility of the first cohort of migrant workers and their health status. Long-term exposure to hazardous work had a greater negative impact on their health. Chinese migrant workers faced significant obstacles in accessing healthcare due to the lack of portability in health insurance.

Conclusion

The study emphasizes the urgent need for addressing the structural barriers hindering healthcare access and outcomes for migrant workers. It is crucial to promote a more equitable and sustainable healthcare system in China to ensure migrant workers' health and well-being.

Disparities in Resource Availability, Psychological Intimate Partner Violence, and Depression Among Hispanic Women

This study aims to analyze the relationship between the availability of resources, exposure to psychological intimate partner violence (P-IPV), and depression in Hispanic women in South Florida. This secondary data analysis used cross-sectional baseline data from SEPA (Salud, Educación, Prevención y Autocuidado) III. SEPA III was a randomized controlled trial that tested the SEPA intervention with 320 cisgender, sexually active Hispanic women. Descriptive analysis, logistic, and multiple regressions were conducted. Lower sexual relationship power and attending religious services were associated with higher odds of P-IPV. Reporting a history of P-IPV in the last 3 months predicted depression scores and higher depression scores were associated with higher odds of experiencing P-IPV. Participants with higher depressive scores reported less education, increased emergency room utilization, and less sexual relationship power. P-IPV is highly prevalent among Hispanic women living in South Florida. The availability of personal and community resources can buffer the risk of P-IPV and its mental health consequences. Nurses can strengthen women's resources to prevent Hispanic women from exposure to P-IPV.

Common resilience factors among healthy individuals exposed to chronic adversity: a systematic review

OBJECTIVE

To identify common resilience factors against non-communicable diseases (dental caries, diabetes type II, obesity and cardiovascular disease) among healthy individuals exposed to chronic adversity.

MATERIALS AND METHODS

The databases MEDLINE (via PubMed), Scopus and CINAHL were searched. Observational studies in English assessing resilience factors among populations living in chronic adversity were included. Intervention studies, systematic reviews, non-original articles and qualitative studies were excluded. There were no restrictions regarding publication year or age. No meta-analysis could be done. Quality assessments were made with the Newcastle-Ottawa scale (NOS).

RESULTS

A final total of 41 studies were included in this systematic review. The investigated health resilience factors were divided into the following domains: environmental (community and family) and individual (behavioural and psychosocial). A narrative synthesis of the results was made according to the domains.

CONCLUSIONS

Individual psychosocial, family and environmental factors play a role as health resilience factors in populations living in chronic adversity. However, the inconclusive results suggest that these factors do not act in isolation but interplay in a complex manner and that their interaction may vary during the life course, in different contexts, and over time.

A scoping review of the impacts of COVID-19 physical distancing measures on vulnerable population groups

Most governments have enacted physical or social distancing measures to control COVID-19 transmission. Yet little is known about the socio-economic trade-offs of these measures, especially for vulnerable populations, who are exposed to increased risks and are susceptible to adverse health outcomes. To examine the impacts of physical distancing measures on the most vulnerable in society, this scoping review screened 39,816 records and synthesised results from 265 studies worldwide documenting the negative impacts of physical distancing on older people, children/students, low-income populations, migrant workers, people in prison, people with disabilities, sex workers, victims of domestic violence, refugees, ethnic minorities, and people from sexual and gender minorities. We show that prolonged loneliness, mental distress, unemployment, income loss, food insecurity, widened inequality and disruption of access to social support and health services were unintended consequences of physical distancing that impacted these vulnerable groups and highlight that physical distancing measures exacerbated the vulnerabilities of different vulnerable populations.

Conceptualizing transgender and gender-diverse older adults as a vulnerable population: A systematic review

BACKGROUND

While extant literature clearly illustrates the negative experiences of transgender and gender-diverse (TGD) people, the intersection between TGD identity and older age in producing vulnerability is poorly understood. The Vulnerable Populations Conceptual Model (VPCM) provides a framework for identifying vulnerable communities. Understanding access to resources, relative risks, and health status experienced by TGD older adults is critical in developing person-centered interventions.

METHODS

A systematic review using PRISMA guidelines was used. CINAHL, Medline, PubMed, and PsycINFO were searched for studies published from 2017 to 2022.

RESULTS

Of the seventeen articles included, no articles were based from a nursing journal. Synthesis of findings described TGD older adults as a vulnerable population with limited access to resources and several risks leading to poor health status.

CONCLUSION

Identifying TGD older adults as a vulnerable population is critical to understand their unique needs. The findings underline implications in nursing education, practice, and research.

Oral Health and Pathologies in Migrants and Vulnerable Population and Their Social Impact: The Good Practices of the Intervention Model of a University Dental Clinic

Numerous studies have shown the high incidence of diseases affecting oral health in vulnerable populations. The Canary Islands is a region particularly affected by the low income of its inhabitants and a high migration rate. Poor oral health habits and limited access to health care have turned these groups into risk groups. The role of the Fernando Pessoa Canarias University (CDUFPC) dental clinic in the health care of these groups has been an example of good professional practice and a fundamental resource in their health care. The present study aims to identify the profile of pathologies as well as the impact on the oral health of vulnerable population groups served by the CDUFPC. This study was developed between September 2019 and July 2022 with a sample of 878 patients, of whom 267 (30.4%) belonged to vulnerable groups referred by institutions and social organizations. The results identified the prevalence of dental caries as the main pathology and the lack of good oral habits and commitment to oral health and care.

Low– and Medium–Socioeconomic-Status Group Members’ Perceived Challenges and Solutions for Healthy Nutrition: Qualitative Focus Group Study

Background

Although digital tools for healthy nutrition have shown great potential, their actual impact remains variable as digital solutions often do not fit users’ needs and barriers. This is especially poignant for priority communities in society. Involving these groups in citizen science may have great benefits even beyond the increase in knowledge of the lives and experiences of these groups. However, this requires specialized skills. Participants from priority groups could benefit from an approach that offers sensitization and discussion to help them voice their needs regarding healthy nutrition and technology to support healthy eating.

Objective

This study aimed to gather insights into people’s thoughts on everyday eating practices, self-regulation in healthy eating, and skill acquisition and on applying technological innovations to these domains.

Methods

Participants answered 3 daily questionnaires to garner their current practices regarding habits, self-regulation, skills, and technology use surrounding healthy eating and make it easier for them to collect their thoughts and experiences (sensitization). Within a week of filling out the 3 questionnaires, participants took part in a web-based focus group discussion session. All sessions were transcribed and analyzed using a thematic qualitative approach.

Results

A total of 42 people took part in 7 focus group interviews of 6 people each. The analysis showed that participants would like to receive support from technology for a broad range of aspects of nutrition, such as measuring the effect their personal nutrition has on their individual health, providing them with reliable product information, giving them practical guidance for healthy eating and snacking, and reducing the burden of registering food intake. Technology should be easy to use, reduce burdens, and be tailored to personal situations. Privacy and cost were major concerns for the participants.

Conclusions

This study shows that people from low– and medium–socioeconomic-status groups have a need for specific support in tailoring their knowledge of healthy nutrition to their own situation and see technology as a means to achieve this.

"It was horrible for that community, but not for the way we had imagined": A qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19

The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs serving communities experiencing marginalisation during COVID-19, and the impact the pandemic and pandemic response have had on physicians' ability to provide care. We conducted semi-structured qualitative interviews with FPs from four Canadian regions, October 2020 through June 2021. We employed maximum variation sampling and continued recruitment until we reached saturation. Interviews explored participants' roles/experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support communities experiencing marginalisation throughout. We used a thematic approach to analyse the data. FPs working with communities experiencing marginalisation expressed the need to continue providing in-person care throughout the pandemic, often requiring them to devise innovative adaptations to their clinical settings and practice. Physicians noted the health implications for their patients, particularly where services were limited or deferred, and that pandemic response policies frequently ignored the unique needs of their patient populations. Pandemic-related precautionary measures that sought to minimise viral transmission and prevent overwhelming acute care settings may have undermined pre-existing services and superseded the ongoing harms that are disproportionately experienced by communities experiencing marginalisation. FPs are well placed to support the development of pandemic response plans that appreciate competing risks amongst their communities and must be included in pandemic planning in the future.

Ethics of participation and social inclusion of older persons in research: lessons learned from the COVID-19 pandemic in Singapore

The COVID-19 pandemic brought about safe distancing measures that are unprecedented. This article details the impact of the pandemic across research studies involving older persons in Singapore, and assesses the different strategies used to adapt to their needs in the context of evolving public health measures. The pandemic exposed diverse experiences of vulnerability among older persons, pushing for critical reflections on ethics of participation and social inclusion as the new research normal. We emphasize the importance of practicing flexibility: consideration for differentiated approaches to recruitment and data collection that should be proactively embedded in research designs for older persons during the pandemic and beyond.

A scoping review of implementation of health-focused interventions in vulnerable populations

Vulnerable populations face significant challenges in getting the healthcare they need. A growing body of implementation science literature has examined factors, including facilitators and barriers, relevant to accessing healthcare in these populations. The purpose of this scoping review was to identify themes relevant for improving implementation of healthcare practices and programs for vulnerable populations. This scoping review relied on the methodological framework set forth by Arksey and O’Malley, and the Consolidated Framework for Implementation Research (CFIR) to evaluate and structure our findings. A framework analytic approach was used to code studies. Of the five CFIR Domains, the Inner Setting and Outer Setting were the most frequently examined in the 81 studies included. Themes that were pertinent to each domain are as follows—Inner Setting: organizational culture, leadership engagement, and integration of the intervention; Outer Setting: networks, external policies, and patients’ needs and resources; Characteristics of the Individual: knowledge and beliefs about the intervention, self-efficacy, as well as stigma (i.e., other attributes); Intervention Characteristics: complexities with staffing, cost, and adaptations; and Process: staff and patient engagement, planning, and ongoing reflection and evaluation. Key themes, including barriers and facilitators, are highlighted here as relevant to implementation of practices for vulnerable populations. These findings can inform tailoring of implementation strategies and health policies for vulnerable populations, thereby supporting more equitable healthcare.

Vulnerability in Children with Celiac Disease: A Scoping Review Protocol

(1) Background: The scientific literature reports that children with celiac disease (CD) are more susceptible to developing physical, psychological and social problems, conditioning their healthy childhood development. Despite this scientific evidence, the knowledge about determinants of vulnerability for the development of such problems is not consistent. In order to search the literature, a scoping review was conducted to analyse and map the evidence on the sociopsychosomatic vulnerability of children with CD and identify the gaps in this topic. (2) Methods: The methodology proposed by the Joanna Briggs Institute will be adopted and aims to identify studies that meet pre-defined eligibility criteria. The survey will include a range of relevant electronic databases as well as grey literature using related terms such as vulnerability, child and celiac disease. (3) Results: This review will consider any type of quantitative, qualitative and mixed studies and systematic reviews, focusing on dimensions of vulnerability in children with CD. The process of selection of studies, data extraction and analysis will be developed by two independent researchers. A third and fourth researcher will be involved in the study when there is no consensus between the previous researchers, as well as for resolving issues regarding the methodological process. (4) Conclusions: Identifying the determinants of vulnerability in children with CD will help nurses to understand the impact on their childhood development and trace possible gaps. This research is registered on the platform Open Science Framework (OSF).

Vulnerability through the Eyes of People Attended by a Portuguese Community-Based Association: A Thematic Analysis

Vulnerability is associated with the individual’s social and biological conditions, but also the conditions of their enveloping environment and society, leading to terms such as vulnerable populations or risk groups. This study aimed to give a voice to people with experiences of vulnerability and explore their perspectives, using a descriptive qualitative design. Purportedly vulnerable adults were recruited and interviewed with semi-structured questions on vulnerability. Data were organized, using WebQDA software, and submitted to thematic content analysis, as proposed by Clark and Braun, which generated a thematic tree. The study included six men and six women with a mean age of 43.8 [SD = 14.17] years old. Thematic analysis generated three themes: (1) Conceptions about vulnerability, (2) Barriers imposed by vulnerability, and (3) Strategies for dealing with vulnerability. The results highlight that vulnerability is a highly dynamic process of openness to circumstances that influence individual outcomes. However, there is a lack of conceptual clarity. Although being vulnerable is perceived as something negative, we need to transform the social mindset, because vulnerability also has the potential to change priorities in life for the better.

The concept of vulnerability in aged care: a systematic review of argument-based ethics literature

BACKGROUND

Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept.

METHODS

Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher's Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology.

RESULTS

Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults' vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults' vulnerability: understanding older adults' vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures.

CONCLUSIONS

The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.

Influence of Social Determinants of Health on COVID-19 Infection in Socially Vulnerable Groups

The coronavirus 2019 (COVID-19) pandemic has had a significant impact on the economy and health, especially for the most vulnerable social groups. The social determinants of health are one of the most relevant risks for becoming infected with COVID-19, due to the health consequences for those who are exposed to it. The objective of this study was to analyze the influence of social determinants in health on COVID-19 infection in vulnerable social groups. A transversal epidemiological study was carried out on 746 individuals in vulnerable situations living in conditions of extreme poverty in disadvantaged areas in the province of Almeria (southeast of Spain). Social determinants of health such access to drinking water (p < 0.001) and economic income (p = 0.04) influenced the infection of COVID-19. A binary logistic regression model showed that the significant predictors of COVID-19 infection were the lack of economic income and inaccessible drinking water. The government and social health services must be aware of this problem in order to play an active role in searching for solutions and implementing public health prevention measures to eliminate social inequalities in health.

Interprofessional primary care practice including social workers: exploring the experiences of patients in vulnerable situations

The link between social inequality and health has been widely recognized, as there are systematic differences in health between people from lower and higher social classes. Furthermore, the complexity and multidimensionality of health and social problems has resulted in primary health care services that are increasingly integrating the approach of interprofessional collaboration between medical professionals and social workers. Despite this current focus, there is a lack of empirical insights into patients' experience of the quality of care resulting from these collaborations. This paper aims to contribute to knowledge by adopting a research approach that captures the narratives of patients in vulnerable situations from a primary care center by conducting semi-structured interviews. Through content analysis, data was analyzed according to five themes: (1) availability, (2) accessibility, (3) affordability, (4) comprehensibility, and (5) usefulness. The results suggest a positive role for interprofessional collaboration between medical professionals and social workers within a primary health care setting. This includes the opportunity for giving greater attention to social rights and collaboration within the local community.

Codesigning person-centred quality indicators with diverse communities: A qualitative patient engagement study

Introduction

Effective engagement of underrepresented communities in health research and policy remains a challenge due to barriers that hinder participation. Our study had two objectives: (1) identify themes of person‐centred care (PCC) from perspectives of diverse patients/caregivers that would inform the development of person‐centred quality indicators (PC‐QIs) for evaluating the quality of PCC and initiatives to improve PCC and (2) explore innovative participatory approaches to engage ethnocultural communities in qualitative research.

Methods

Drawing on participatory action research methods, we partnered with a community‐based organization to train six ‘Community Brokers’ from the Chinese, Filipino, South Asian, Latino‐Hispanic, East African and Syrian communities, who were engaged throughout the study. We also partnered with the provincial health organization to engage their Patient and Family Advisory, who represented further aspects of diversity. We conducted focus group discussions with patients/caregivers to obtain their perspectives on their values, preferences and needs regarding PCC. We identified themes through our study and engaged provincial stakeholders to prioritize these themes for informing the development of PC‐QIs and codesign initiatives for improving PCC.

Results

Eight focus groups were conducted with 66 diverse participants. Ethnocultural communities highlighted themes related to access and cost of care, language barriers and culture, while the Patient and Family Advisory emphasized patient and caregiver engagement. Together with provincial stakeholders, initiatives were identified to improve PCC, such as codesigning innovative models of training and evaluation of healthcare providers.

Conclusion

Incorporating patient and community voices requires addressing issues related to equity and understanding barriers to effective and meaningful engagement.

Patient or Public Contribution

Patient and public engagement was central to our research study. This included partnership with a community‐based organization, with a broad network of ethnocultural communities, as well as the provincial health service delivery organization, who both facilitated the ongoing engagement of diverse patients/caregiver communities throughout our study including designing the study, recruiting participants, collecting and organizing data, interpreting findings and mobilizing knowledge. Drawing from participatory action research methods, patients and the public were involved in the codesign of the PC‐QIs and initiatives to improve PCC in the province based on the findings from our study.

Psychosocial vulnerability among carers of persons living with a chronic illness: A scoping review

AIMS

To outline and examine evidence related to the meaning of 'psychosocial vulnerability' among caregivers of persons with chronic illnesses.

BACKGROUND

The number of informal caregivers continues to rise globally. Their risk of psychosocial vulnerability is frequently overlooked, but understanding their psychosocial vulnerability may offer insights into meeting their needs.

DESIGN

Scoping review following the PRISMA 2020 extension guidelines.

DATA SOURCES

The databases CINAHL, Embase, Medline/Pubmed, Cochrane Library, PsycINFO, Web of Science, Google Scholar, Lenus and ProQuest were systematically searched to identify original research. No date limit was set, and 23 studies were included.

REVIEW METHODS

A five-step approach using the Arksey and O'Malley framework. Thematic analysis guided data analysis.

RESULTS

Carers' psychosocial vulnerability occurs when they experience barriers to resources while access and use of supports reduce risk. Antecedents of psychosocial vulnerability include a carer's age and sex, socioeconomic status and their health and wellbeing. Psychosocial vulnerability affects carers' relationships and causes personal losses.

CONCLUSIONS

The concept of carers' psychosocial vulnerability is complex. Recognition of carers at risk for psychosocial vulnerability would help nurses direct relevant support and information to carers who need it most.

Typologies of Sexual Health Vulnerability Predicting STI Preventive Behaviors Among Latinx Adults in the U.S.: A Latent Class Analysis Approach

Vulnerability to poor sexual health among U.S. Latinx populations is poorly understood, despite high STI rates. We examined how vulnerability typologies differ in their STI preventive behaviors. Using data from the 2016 National Health Interview Survey, we performed latent class analysis to test the association between sexual health vulnerability and HIV testing, hepatitis testing or vaccination, and HPV vaccination from a subsample of Latinx adults. Three classes emerged: Under-Employed Females with Health Care Access, Slightly Under-Employed Females with Some Health Care Access, and Employed Males without Health Care Access. Slightly Under-Employed Females with Some Health Care Access were associated with lack of HIV testing, hepatitis B and C testing, and HPV vaccination. Employed Males without Health Care Access were associated with lack of HIV testing and HPV vaccination. Sexual health vulnerability may be associated with certain STI preventive behaviors, which can inform and refine sexual health promotion programming.

Lessons learned in preventing COVID-19 within a skilled nursing facility during the early pandemic

Objective

Guided by the vulnerable population framework, the aim was to describe the risks and protective strategies for COVID-19 spread and infections in a Skilled Nursing Facility (SNF).

Method

We conducted a retrospective cohort (March 1st–August 31st, 2020) study. Data were collected from internal COVID-19 documents and resident electronic health records. Data were summarized and analyzed using descriptive statistics, relative risk calculations, and cases charted by week onset.

Results

There were 325 residents who lived in and 296 staff who worked at the SNF during the study period. There was a total of 2 confirmed cases among residents and 4 confirmed cases among staff. Cases were isolated and all were living at their baseline health status at the end of the study.

Conclusion

Understanding the vulnerability to and protective strategies for COVID-19 within SNFs could strengthen resident care, resiliency among the SNF community, and improve health policies.

Factors Associated with Mental Health Service Utilization Among Ethiopian Immigrants and Refugees

This study assesses factors associated with mental health service utilization by Ethiopian immigrants and refugees in the U.S. A cross-sectional survey, based on Anderson and Newman's Framework of Health Services, which examines facilitators and barriers of service utilization, was implemented to gather data from 297 Ethiopian immigrants and refugees in the U.S. from February to March 2018. Descriptive statistics, chi-squared tests, and logistic regression were calculated. Approximately 13.3% of participants sought mental health services from healthcare professionals; while 17.3% utilized non-healthcare professionals for mental health problems. A mental health need (depressive symptoms) was identified. A model containing predictors of mental health service use was statistically significant, with gender, marital status, and employment (full-time or part-time) as the strongest predictors. The findings suggest a need for the development of culturally appropriate interventions and implementation of policies to minimize barriers to mental health services among this under-researched population.

Physical and Psychological Health of African American Women Caregivers: Unmasking the Paradox

Existing evidence consistently shows that African American (AA) caregivers experience a health paradox; participants of AA ethnicity have commonly reported having worse physical health but better mental health related to caregiver burden when compared to other racial groups. However, inconsistencies exist in the literature regarding mental health outcomes for this population. In order to provide culturally appropriate, health-promoting interventions, it is imperative to identify accurately the impact of caregiving burden on the mental health of AAs. Fifteen reports of research on the influence of caregiver burden on health were reviewed to evaluate the legitimacy of the paradox (that may be better explained by the term, 'masking'). The appropriateness of two stress process models and the adequacy of comparative research versus culturally-focused studies for AA women caregivers were examined also.

Adolescent Fathers' Perceptions and Experiences of Fatherhood: A Qualitative Exploration with Hispanic Adolescent Fathers

PURPOSE

The purpose of this secondary analysis of qualitative data was to understand the multifactorial influences that impact the health and health behaviors of Hispanic adolescent fathers DESIGN & METHODS: Qualitative description was the method used for this secondary analysis. The theoretical domains of the Vulnerable Populations Conceptual Framework were used to guide this study. The semi-structured interviews of 17 participants were analyzed using qualitative content analysis. Participants were Hispanic adolescent fathers, between the ages of 16 and 23 years, who were attending a fatherhood program.

RESULTS

Most participants came from socioeconomically disadvantaged backgrounds and unstable families. Additionally, their exposure to widespread neighborhood and domestic violence resulted in gang involvement and illegal activities. The cumulative impact of adverse childhood events resulted in substance use and psychological distress. However, becoming a father was transformative, motivating adolescents to stop engaging in destructive, unhealthy behaviors.

CONCLUSION

Adolescent fathers' well-being is an important component of perinatal health because it affects family functioning and health outcomes in their children. The perinatal period presents a "golden" opportunity to promote health and should be leveraged by nurses to allow adolescent fathers to become involved during the perinatal period.

PRACTICE IMPLICATIONS

A family-centered approach is critical in addressing the complex needs of this population. An assessment of their psychosocial environment, including childhood trauma, is necessary to help nurses identify at-risk fathers. Additionally, trauma informed care is a valuable tool that nurses can utilize to foster trust in Hispanic adolescent fathers.

Public Stigma Toward Female and Male Opium and Heroin Users. An Experimental Test of Attribution Theory and the Familiarity Hypothesis

Drug abuse and addiction exist around the world. People addicted to drugs such as opium or heroin often encounter dehumanizing discriminatory behaviors and health-care systems that are reluctant to provide services. Experiencing discrimination often serves as a barrier to receiving help or finding a home or work. Therefore, it is important to better understand the mechanisms that lead to the stigmatization of drug addiction and who is more prone to stigmatizing behaviors. There is also a dearth of research on whether different patterns of stigma exist in men and women. Therefore, this study investigated factors affecting gender-specific stigmatization in the context of drug addiction. In our vignette study (N _Mensample = 320 and N _Womensample = 320) in Iran, we experimentally varied signals and signaling events regarding a person with drug addiction (i.e., N _Vignettes = 32 per sample), based on Attribution Theory, before assessing stigmatizing cognitions (e.g., blameworthiness), affective responses (e.g., anger), and discriminatory inclinations (e.g., segregation) with the Attribution Questionnaire. We also tested assumptions from the Familiarity Hypothesis by assessing indicators of respondents' familiarity with drug addiction (e.g., knowledge about addiction). Results, for example, show higher stigma if the person used "harder" drugs, displayed aggressive behavior, or had a less controllable drug urge. Self-attributed knowledge about addiction or prior drug use increased some forms of stigma, but diminished others. These findings only partially converged between men and women. We suggest that anti-stigma initiatives should consider information about the stigmatized person, conditions of the addiction, and characteristics of stigmatizers.

Factors Influencing Suicidal Ideation and Attempts among Older Korean Adults: Focusing on Age Discrimination and Neglect

This study was conducted to identify factors influencing the development of suicidal ideation and the transition from suicidal ideation to attempts by focusing on experiences of age discrimination and neglect among older Korean adults. This study analyzed data from 10,042 older adults from the 2017 National Survey of Older Koreans using national representative samples. Multiple logistic analyses were used to identify factors influencing the development of suicidal ideation and transition from suicidal ideation to attempts. While younger age, higher educational attainment, living alone, number of chronic diseases, depressive symptoms, social isolation, social support, experience of neglect, and age discrimination influenced the development of suicidal ideation, all of these did not influence the transition from ideation to attempts. Factors influencing this transition included male gender, less educational attainment, and experience of age discrimination. Thus, social efforts to reduce age discrimination are necessary to prevent suicide attempts among Korean older adults.

Vulnerability as a palimpsest: Practices and public policy in a Mexican hospital setting

Vulnerability is a concept associated with the effects of social inequities to access health care services. On a hospital level, vulnerable populations must be identified and favored over others. The aims of this study were the analysis of the conceptions and practices of social workers regarding vulnerable patients, and the identification of theoretical elements of vulnerability given by academics. Hospital ethnography and a focus group were implemented. Social workers related vulnerability to the social needs of each patient; however, they state that they have dilemmas to identify a person in a vulnerable condition; these dilemmas are related to social differences and deservingness. Academics indicated that the vulnerability should refer to the lack of access to health services offered by the institution. Academics agree with social workers regarding the importance of considering the overlapped social and individual circumstances in each patient to recognize their vulnerable condition, regardless of belonging to any of the pre-established vulnerable groups. Finally, taking into account the way of conceptualizing vulnerability and how public policy on the identification of vulnerable patients in the hospital has been implemented, these two elements are explained using the palimpsest model, which is a figure of thought that can be applied to analyze the sociocultural significance of this complex issue, as well as other social dynamics.

Highly vulnerable communities and the Affordable Care Act: Health insurance coverage effects, 2010-2018

Initially implemented in 2014 in some U.S. states, the Medicaid expansions under the Affordable Care Act (ACA) aimed to make health insurance coverage more accessible to the low-income population. This paper aims to quantify the impact of the ACA Medicaid expansions on insurance coverage among racial/ethnic minorities, immigrants, single mothers, veterans, and low-education whites-i.e., the sectors of the population identified with some of the highest healthcare needs. We focus on individuals 18-64 years of age earning 138% or less of the federal poverty level from the American Community Survey, 2010-2018 (n = 2,927,402). We use difference-in-differences (DD) and difference-in-difference-in-differences (DDD) approaches with propensity scores matched comparison groups to estimate pre-post ACA insurance coverage differences between individuals living in states that participated in the ACA Medicaid expansions and those living in non-participating states, and to estimate if such differences vary across subgroups. We find that insurance coverage rates increased for all subgroups; yet, the ACA benefits have not been evenly distributed across them. Low-education whites, non-Hispanic whites, females, and non-Hispanic Native Americans exhibited the highest improvements in insurance coverage. Our results contribute to the understanding of recent trends in racial and socioeconomic disparities in healthcare and the appropriate policy prescriptions to ameliorate them.

Direct-to-Consumer Advertising for Cancer Centers and Institutes: Ethical Dilemmas and Practical Implications

In the United States, many cancer centers advertise their clinical services directly to the public. Although there are potential public benefits from such advertising, including increased patient awareness of treatment options and improved access to care and clinical trials, there is also potential for harm through misinformation, provision of false hope, inappropriate use of health care resources, and disruption in doctor-patient relationships. Although patient education through advertising is appropriate, misleading patients in the name of gaining market share, boosting profits, or even boosting trial accrual is not. It is critical that rigorous ethical guidelines are adopted and that oversight is introduced to ensure that cancer center marketing supports good patient care and public health interests. Patients with cancer have been identified as an especially vulnerable population because of fears and anxiety related to their diagnosis and the very real need to identify optimal sources of care. Cancer organizations have a fiduciary duty and a moral and legal obligation to provide truthful information to avoid deceptive, inaccurate claims associated with treatment success. In this article, actionable recommendations are provided for both the oncologist and the cancer center's marketing team to promote ethical marketing of services to patients with cancer. This tailored guidance for the oncology community includes explicit communication on (1) ensuring fair and balanced promotion of cancer services, (2) avoiding exaggeration of claims in the context of reputational marketing, (3) providing data and statistics to support direct and implied assertions of treatment success, and (4) defining eligible patient groups in the context of marketing for research. These recommendations for cancer centers are designed to promote ethical quality marketing information to patients with cancer.

Citizenship and health insurance status predict glycemic management: NHANES data 2007-2016

The prevalence of diabetes in United States (US) immigrants is higher than the general population. Non-citizenship and lack of health insurance have been associated with increased health risks including diabetes, but previous US studies were done in non-representative samples and did not examine the effect on glycemic management. The purpose of this study was to compare demographic, metabolic, and behavioral risk factors for increased blood glucose including citizenship and health insurance status, and determine predictors of poor glycemic management (A1C ≥ 8.0%). Logistic regression was used to analyze data from the 2007-2016 National Health and Nutrition Examination Surveys (NHANES) of persons with diabetes and available citizenship data ages 30 to 70 years (N = 2702), excluding persons with A1C < 5% and pregnant women. Results represent the weighted sample. Among participants, 92% indicated citizenship by birth (81%) or naturalization (11%). Insured rates increased from 83% to 91% between 2007 and 2008 and 2015-2016 (p < .001). Citizenship was positively associated with insurance status, higher income and education, better diet, increased smoking, and more sedentary hours (ps < .05). Non- citizens (OR: 1.74, 95% CI: 1.20-2.51) and uninsured persons (OR: 1.99, 95% CI: 1.53-2.59) were nearly twice as likely to have poor glycemic management than US citizens by naturalization and insured individuals respectively. We conclude that citizenship and absence of health insurance negatively impacts diabetes management. Policy decisions are needed that address primary and secondary prevention strategies for individuals without citizenship and health insurance to reduce diabetes burden in the US.

Implementation of health-focused interventions in vulnerable populations: protocol for a scoping review

INTRODUCTION

Vulnerable populations face significant challenges in navigating the care continuum, ranging from diagnosis of illness to linkage and retention in healthcare. Understanding how best to move individuals within these vulnerable populations across the care continuum is critical to improving their health. A large body of literature has focused on evaluation of implementation of various health-focused interventions in this population. However, we do not fully understand the unique challenges to implementing healthcare interventions for vulnerable populations. This study aims to examine the literature describing implementation of health service interventions among vulnerable populations to identify how implementations using the Consolidated Framework for Implementation Research are adapted. Findings from this review will be useful to implementation scientists to identify gaps in evidence and for adapting similar interventions in unique settings.

METHODS AND ANALYSIS

This study protocol outlines a scoping review of the peer-reviewed and grey literature, using established approaches delineated in Arksey and O'Malley's scoping review framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. Search strategies will be developed and refined by a medical librarian in collaboration with the research team. Searches will be conducted in electronic databases (CINAHL, Cochrane, PsychINFO, PubMed, Social Services Abstracts, Web of Science, Google and Google Scholar) and limited to studies published between 1 August 2009 and 1 June 2020. Additionally, hand searches will be conducted in three relevant journals-Implementation Science, Systematic Reviews and BMJ Open. English-language studies and reports meeting inclusion criteria will be screened independently by two reviewers and the final list will be abstracted and charted in duplicate.

ETHICS AND DISSEMINATION

This is a review of the literature; ethics approval is not indicated. We will disseminate findings from this study in peer-reviewed journals as well as presentations to relevant stakeholders and conferences.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Defining vulnerability in European pregnant women, a Delphi study

OBJECTIVE

Vulnerability among pregnant women is an important and complex theme in the everyday practice of midwives. Exchanging knowledge and best practices about vulnerability between midwives in Europe can contribute to improving the knowledge and skills of midwives and as a result improve the care for vulnerable pregnant women. We therefore start a consortium with midwives, midwifery teachers, researchers and students from organizations of seven European cities with the aim to exchange knowledge and best practices concerning vulnerable pregnant women between midwives. To be able to effectively exchange knowledge and best practices, our consortium started with this study focuses on establishing a mutual definition of vulnerable pregnant women. Therefore, the aim of this study is to develop a mutual definition of vulnerable pregnant women and to identify aspects related to vulnerability.

DESIGN

Delphi study with four rounds: (1) gathering existing knowledge from literature and definitions used by partners of the consortium, (2) and (3) two survey rounds and (4) an in-person consensus meeting.

SETTING

Consortium of midwives, midwifery teachers, researchers and students from Antwerp (Belgium), Ghent (Belgium), Turku (Finland), Milan (Italy), Piła (Poland), Lisbon (Portugal) and Rotterdam (The Netherlands) PARTICIPANTS: We included all consortium members in the Delphi study.

FINDINGS

Various aspects related to vulnerability and appropriate definitions were identified during the Delphi rounds. Consensus about the aspects related to vulnerability and the definition of vulnerable pregnant women was reached during the final consensus meeting. A vulnerable pregnant woman was defined as a woman who is threatened by physical, psychological, cognitive and/or social risk factors in combination with lack of adequate support and/or adequate coping skills.

KEY CONCLUSION

We reached consensus about a mutual definition of vulnerable pregnant women and aspects related to vulnerability within this consortium. The Delphi approach led to interesting discussions and was a valuable method to define the concept of vulnerable pregnant women within our project .

IMPLICATIONS FOR PRACTICE

In order to accomplish a project that aimed to improve care for vulnerable pregnant women it was important to first identify the population of vulnerable pregnant women with a mutual definition.

The long and winding road to happiness: A randomized controlled trial and cost-effectiveness analysis of a positive psychology intervention for lonely people with health problems and a low socio-economic status

Background

Our objective was to evaluate the effectiveness and cost-effectiveness of the positive psychology intervention ‘Happiness Route’ compared to an active control condition in a vulnerable population with an accumulation of health and psychosocial problems.

Methods

We conducted a randomized, single-blind, actively-controlled, parallel group study in seven municipalities in the Netherlands. To be eligible, participants had to experience loneliness, health problems and low socio-economic status. Each group received several home visits by a counsellor (two in the control condition, two to six in the experimental condition). In the Happiness Route, a happiness-based approach was used, whereas the control condition used a traditional problem-based approach. The primary outcome was well-being, measured with the Mental Health Continuum-Short Form (MHC-SF).

Results

Fifty-eight participants were randomized to the Happiness Route, 50 to the control condition. Participants were severely lonely, had on average three health problems and less than 5% had paid work. The total MHC-SF score, emotional and social well-being, depression and loneliness improved significantly over the nine-month period in both conditions (p < .05), but there were no significant changes between the conditions across time. Languishing decreased significantly from 33% at baseline to 16% at follow-up among the Happiness Route participants but did not change significantly in the control condition. No significant improvement over time was found in psychological well-being, resilience, purpose in life, health-related quality of life and social participation. Cost-effectiveness analysis showed that expected saved costs per QALY lost was €219,948 for the Happiness Route, relative to the control condition. The probability was 83% that the Happiness Route was cost saving and 54% that the Happiness Route was cost-effective at a willingness to accept a threshold of €100,000.

Conclusions

Mental health status of both groups improved considerably. However, we could not demonstrate that the Happiness Route yielded better health outcomes compared to the control condition. Nevertheless, the results of the cost-effectiveness analysis suggested that the Happiness Route is an acceptable intervention from a health-economic point of view. Our results should be viewed in light of the fact that we could not include the planned number of participants.

Trial registration

Netherlands Trial Register: NTR3377. Registered 2 Apr 2012.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Interprofessional and intersectoral collaboration in the care of vulnerable pregnant women: An interpretive study

'Vulnerable' is a term often used for pregnant women in need of extended antenatal care, although the term is not well defined. This study focuses on healthcare professionals' interpretations and understanding of vulnerability in pregnancy, including their own role, to understand the practices of interprofessional and intersectoral collaboration in antenatal care for vulnerable pregnant women. Intrepretive Description informed the methodology of the study and the theoretical framework was inspired by Symbolic Interactionism. It was found that definitions of vulnerability in pregnancy are fluid, being based on the healthcare professional's individual assessment of the pregnant woman´s personal resources, personal characteristics and psychological factors, and that these definitions also depend on the healthcare professional's role in relation to the pregnant woman. The different interprofessional teams' identification of what constitutes vulnerability in a pregnant woman was complex and relied on different components. Interprofessional collaboration was influenced by the relationships between professionals and sectors involved in antenatal care for pregnant women and was thereby influenced by the settings and structures in place for interprofessional and intersectoral collaboration. Insight into the healthcare professionals' perspectives of vulnerability in pregnancy can help develop and improve the interprofessional and intersectoral collaboration in antenatal care of vulnerable pregnant women and their unborn babies.

Deploying the Precautionary Principle to Protect Vulnerable Populations in Canadian Post-Market Drug Surveillance

Drug regulatory bodies aim to ensure that patients have access to safe and effective drugs; however, no matter the quality of pre-licensure studies, uncertainty will remain regarding the safety and effectiveness of newly approved drugs until a large and diverse population uses those drugs. Recent analyses of Canada’s post-market drug surveillance (PMDS) system have found that Canada’s PMDS system requires strengthening and that efforts must be improved to monitor and address the safety and effectiveness of approved drugs among vulnerable populations. Given the uncertainty that exists when drugs enter the market, some have suggested that the precautionary principle is relevant to guiding decision-making in this context. This paper responds to recommendations that the Canadian PMDS system should be responsive to the health needs of vulnerable populations by assessing the utility of deploying the precautionary principle to guide a post-market strategy for vulnerable populations.

The modification of three vulnerability theories to assist nursing practice for school-age children with severe asthma

PURPOSE

Severe asthma is an inflammatory illness associated with adverse health outcomes and behaviors in children, such as decreased quality of life, impaired sleep, and increased medical costs and morbidity.

CONCLUSIONS

Children with severe asthma frequently exhibit a cycle of health and behaviors which contribute to these adverse health outcomes, consisting of decreased physical activity, increased stress, and increased airway inflammation and asthma exacerbations. School-age children, in particular, are a vulnerable population because they not only rely on others for their care but also suffer from a chronic illness and are at risk for unequal healthcare access and health outcomes.

PRACTICE IMPLICATIONS

Currently, there is no one nursing theory that adequately addresses the vulnerability, cycle of health and behaviors, and adverse health outcomes of children with severe asthma. By integrating key concepts from three vulnerability theories and presenting a modified conceptual framework, this paper aims to demonstrate how the use of this new conceptual framework may assist nurses in evaluating the unique needs of school-age children with severe asthma to provide best practices and develop appropriate interventions.

Factors associated with local herb use during pregnancy and labor among women in Kigoma region, Tanzania, 2014-2016

Background

Despite research suggesting an association between certain herb use during pregnancy and delivery and postnatal complications, herbs are still commonly used among pregnant women in sub-Sahara Africa (SSA). This study examines the factors and characteristics of women using local herbs during pregnancy and/or labor, and the associations between local herb use and postnatal complications in Kigoma, Tanzania.

Methods

We analyzed data from the 2016 Kigoma Tanzania Reproductive Health Survey (RHS), a regionally representative, population-based survey of reproductive age women (15–49 years). We included information on each woman’s most recent pregnancy resulting in a live birth during January 2014–September 2016. We calculated weighted prevalence estimates and used multivariable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with use of local herbs during pregnancy and/or labor, as well as factors associated with postnatal complications.

Results

Of 3530 women, 10.9% (CI: 9.0–13.1) used local herbs during their last pregnancy and/or labor resulting in live birth. The most common reasons for taking local herbs included stomach pain (42.9%) and for the health of the child (25.5%). Adjusted odds of local herb use was higher for women reporting a home versus facility-based delivery (aOR: 1.6, CI: 1.1–2.2), having one versus three or more prior live births (aOR: 1.8, CI: 1.4–2.4), and having a household income in the lowest versus the highest wealth tercile (aOR: 1.4, CI: 1.1–1.9). Adjusted odds of postnatal complications were higher among women who used local herbs versus those who did not (aOR: 1.5, CI: 1.2–1.9), had four or more antenatal care visits versus fewer (aOR: 1.4, CI: 1.2–1.2), and were aged 25–34 (aOR: 1.1, CI: 1.0–1.3) and 35–49 (aOR: 1.3, CI: 1.0–1.6) versus < 25 years.

Conclusions

About one in ten women in Kigoma used local herbs during their most recent pregnancy and/or labor and had a high risk of postnatal complications. Health providers may consider screening pregnant women for herb use during antenatal and delivery care as well as provide information about any known risks of complications from herb use.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

Background

Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants.

Objective

This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups.

Methods

In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate.

Results

Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups.

Conclusions

eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.

Patients' experiences of a mindfulness intervention for adults with advanced cancer: a qualitative analysis

PURPOSE

People with advanced cancer often experience significant emotional turmoil that accompanies their diagnosis and cancer-related treatments. Therefore, psychological interventions become relevant to address these impacts; however, there is a lack of research into the psychological support needs of those with advanced cancer (those not yet in palliative or end-of-life stages). In this context, we developed a mindfulness-based intervention, Coping with Cancer Mindfully (CCM), to provide psychological and emotional support to adults with advanced cancer. This article reports on qualitative interviews from a mixed method study of the CCM intervention exploring its utility and the extent it provides psychological support to this population in a pre-post-intervention design.

METHODS

Adults with advanced cancer (stage III or IV) were recruited via cancer-related services in Christchurch, New Zealand. Thematic analysis was used to analyse the semi-structured interviews.

RESULTS

Twenty participants were interviewed. Thematic analysis showed that at baseline, participants were experiencing distress but few had been offered psychological support; they reported feeling vulnerable and battling their cancers, and were seeking help. Post-intervention interviews reported that most participants' perspectives had shifted, from a state of vulnerability to one of self-encouragement, increased optimism, and taking new actions regarding their situations. The CCM intervention was identified as a readily available and positive tool of support.

CONCLUSIONS

Our findings suggest that those with advanced cancer should be offered options of psychological support at any stage post-diagnosis. At such an intense period in their lives, people with advanced cancer are likely to benefit from tailored psychological interventions. The CCM intervention with its focus on acceptance, meaning in life, and mindful coping has been shown to be acceptable to participants and as a supportive tool.