Development and Testing of the Relational and Structural Components of Innovativeness Across Academia and Practice for Healthcare Progress Scale

OBJECTIVE

Using data from 5 academic-practice sites across the United States, researchers developed and validated a scale to measure conditions that enable healthcare innovations.

BACKGROUND

Academic-practice partnerships are a catalyst for innovation and healthcare development. However, limited theoretically grounded evidence exists to provide strategic direction for healthcare innovation across practice and academia.

METHODS

Phase 1 of the analytical strategy involved scale development using 16 subject matter experts. Phase 2 involved pilot testing the scale.

RESULTS

The final Innovativeness Across Academia and Practice for Healthcare Progress Scale (IA-APHPS) consisted of 7 domains: 3 relational domains, 2 structural domains, and 2 impact domains. The confirmatory factor analysis model fits well with a comparative fit index of 0.92 and a root-mean-square error of approximation of 0.06 (n = 477).

CONCLUSION

As the 1st validated scale of healthcare innovation, the IA-APHPS allows nurses to use a diagnostic tool to facilitate innovative processes and outputs across academic-practice partnerships.

Impact of Telemedicine on Access to Care for Rural Transgender and Gender-Diverse Youth

OBJECTIVE

To explore the impact of telemedicine on access to gender-affirming care for rural transgender and gender diverse youth.

STUDY DESIGN

A retrospective analysis of data drawn from the electronic medical records of a clinic that provides approximately 10 000 adolescent and young adult visits per year and serves patients seeking gender health care. The no-show rate was examined as a proxy for access to care due to anticipated challenges with recruiting a representative sample of a historically marginalized population. Logistic regression with generalized estimating equations was conducted to model the association between the odds of a no-show visit and covariates of interest.

RESULTS

Telemedicine visits, rural home address, gender health visits, longer travel time, and being younger than 18 years old were associated with lower odds of a no-show in univariate models (n = 17 928 visits). In the adjusted model, the OR of no-shows for gender health visits was 0.56 (95% CI 0.42-0.74), adjusting for rurality, telemedicine, age (< or >18 years), and travel time to the clinic.

CONCLUSIONS

In this study, telemedicine was associated with reduced no-shows overall, and especially for rural, transgender and gender diverse youth, and patients who hold both identities. Although the no-show rate does not fully capture barriers to access, these findings provide insight into how this vulnerable population may benefit from expanded access to telemedicine for rural individuals whose communities may lack providers with the skills to serve this population.

Back to basics: Practical strategies to reduce sensory overstimulation in the emergency department identified by adults and caregivers of children with autism spectrum disorder

INTRODUCTION

Sensory overstimulation of autistic patients of all ages during an ED visit can ultimately lead to care escalation, but few studies have evaluated patient perspectives on improving the ED sensory experience across the age continuum. The purpose of this study was to explore patient-centered perspectives on reducing adult and pediatric autistic patients' sensory stimulation during an ED visit.

METHODS

We used a qualitative descriptive design to explore how autistic patients experience sensory disruption and recommendations to improve care. Data were analyzed inductively using an overall categorization of 6 senses (visual, auditory, touch, smell, taste, and proprioception).

RESULTS

Fourteen adults and 30 caregivers of children provided written responses to open-ended interview questions (n = 44). Participants suggested strategies to minimize the sensory disruption they experienced; however, an overarching recommendation was for clinicians to ask about their or their child's preferences before delivering care or services.

CONCLUSION

Because people with autism are more likely to visit an ED than their neurotypical counterparts, ED clinicians should be proficient in "sensory-friendly care." A variety of evidence-based practical strategies and design approaches exist that can be leveraged to reduce the risk of care escalation; however, the most basic may be to prioritize asking patients and their caregivers about their preferences prior to providing care.

Climate and human mortality in Virginia, 2005-2020

Using an extensive database of every resident death in Virginia from 2005 to 2020, climate-mortality relationships are examined for 12 climatically homogeneous regions within the Commonwealth. Each region is represented by a first-order weather station from which archived temperature and humidity data are used to generate a variety of biometeorologically relevant indices. Using these indices and other variables (such as air quality and heat and cold waves), daily mortality and climate relationships are modeled for each region over a 21-day lag period utilizing generalized additive models and distributed lag non-linear models. Optimal models are identified for each region, and a consensus model was also run based on maximum temperature to facilitate inter-regional comparisons. The relative risk of mortality varies markedly as a function of climate between regions, with U-shaped, J-shaped, and inverse linear relationships evident. Cold mortality exceeds heat mortality across most of Virginia (typical relative risks are 1.10 for cold and 1.03 for heat), with cold risks strongest at lags 3 to 10. Low temperatures (or low humidity) are protective at lags 0-2 days except in the colder, western parts of state. Heat mortality occurs at short lags (0-2 days) for three-fourths of the stations, but the spatial pattern is random. Mortality displacement is evident for most regions for several days following the heat-related spike. Although the use of region-specific models is justified, the simple consensus model based on a consistent set of predictors provides similar results.

Extending health care access via telemedicine in public libraries

BACKGROUND

Despite the potential for telemedicine in public libraries to expand health care access to those living a long distance from care and in broadband poor areas, there are few libraries that collaborate with providers to extend access.

PURPOSE

To explore licensed health care providers' perspectives on telemedicine in public libraries as a method of improving equitable access to care for populations lacking the ability to connect to telemedicine from home.

METHODS

We used a two-phase explanatory sequential mixed methods design with a quantitative strand followed by a qualitative strand. Surveys were analyzed descriptively. Interviews were analyzed thematically using descriptive content analysis.

RESULTS

Of the 50 survey respondents, 13 were physicians and 36 were nurse practitioners (NPs); 12 NPs were interviewed. NPs were overwhelmingly supportive of telemedicine in public libraires, describing how connecting at-risk populations to a video visit (VV) allowed for a more thorough and accurate assessment than a phone call. Although several NPs were concerned with privacy, others considered a library to be more private than the home. Interviews revealed how chronic illness management may be the ideal visit type for public library-based telemedicine.

CONCLUSIONS

Given the importance of expanding access sites for telemedicine, NPs should consider partnering with libraries in their catchment areas where broadband access is sparse and patients must travel long distances to care.

IMPLICATIONS

Managing chronic illnesses using telemedicine in public libraries may be an important approach toward reducing health disparities in populations who live in long distances from care and do not have home-based internet access.

Rural Cancer Survivors' Perceptions of a Nurse-Led Telehealth Intervention to Manage Cancer-Related Distress

OBJECTIVES

To understand rural survivors' experiences of participating in a nurse-led telehealth visit designed to address cancer-related distress.

SAMPLE & SETTING

25 rural-dwelling, post-treatment adult survivors of head and neck cancer recruited from a cancer center clinic affiliated with an academic health system serving a rural catchment area in the southeastern United States.

METHODS & VARIABLES

A descriptive multimethod approach using semistructured qualitative interviews and the Telemedicine Satisfaction and Usefulness Questionnaire.

RESULTS

Three primary themes emerged from the qualitative interviews, related to trust, access to information, and technology barriers. Quantitative findings indicated high satisfaction with the nurse-patient relationship through telehealth and lower satisfaction with using telehealth equipment to connect to a visit.

IMPLICATIONS FOR NURSING

Despite facing technology barriers, rural cancer survivors prioritize speaking with an oncology certified nurse through telehealth. Although they may be willing to be open and vulnerable with an oncology nurse about their distress, rural survivors are less likely to accept a referral to another provider of psychosocial care. Nurses can incorporate warm handoffs to increase psychosocial referral uptake for rural survivors.

Cancer-Related Distress: Symptom Clusters in Rural Head and Neck Cancer Survivors

BACKGROUND

Rural post-treatment head and neck cancer (HNC) survivors experience high rates of cancer-related distress and may experience unique symptom clusters. Oncology nurses can benefit from a better understanding of the symptom clusters that HNC survivors experience.

OBJECTIVES

The purpose of this secondary data analysis was to identify symptom clusters of cancer-related distress in rural HNC survivors.

METHODS

Secondary data analysis was conducted with survey data collected from rural HNC survivors (N = 20). Distress symptoms were measured using the National Comprehensive Cancer Network Distress Thermometer and Problem List, amended for a population with HNC. Symptom clusters were defined as two or more co-occurring symptoms and evaluated based on participant-reported severity using exploratory factor analysis. Resultant clusters were assessed for theoretical and clinical appropriateness.

FINDINGS

Preliminary analysis suggests rural HNC survivors experience eight symptom clusters. As a first step, the results of this study can help nurses to identify symptom clusters in rural HNC survivors.

Exploration of shared decision making in oncology within the United States: a scoping review

PURPOSE

Shared decision making (SDM) among the oncology population is highly important due to complex screening and treatment decisions. SDM among patients with cancer, caregivers, and clinicians has gained more attention and importance, yet few articles have systematically examined SDM, specifically in the adult oncology population. This review aims to explore SDM within the oncology literature and help identify major gaps and concerns, with the goal to provide guidance in the development of clear SDM definitions and interventions.

METHODS

We conducted a scoping review using the Arksey and O'Malley approach along with the PRISMA Extension for Scoping Reviews Checklist. A systematic search was conducted in four databases that included publications since 2016.

RESULTS

Of the 364 initial articles, eleven publications met the inclusion criteria. We included articles that were original research, cancer related, and focused on shared decision making. Most studies were limited in defining SDM and operationalizing a model of SDM. There were several concerns revealed related to SDM: (1) racial inequality, (2) quality and preference of the patient, caregiver, and clinician communication is important, and (3) the use of a decision-making aid or tool provides value to the patient experience.

CONCLUSION

Inconsistencies regarding the meaning and operationalization of SDM and inequality of the SDM process among patients from different racial/ethnic backgrounds impact the health and quality of care patients receive. Future studies should clearly and consistently define the meaning of SDM and develop decision aids that incorporate bidirectional, interactive communication between patients, caregivers, and clinicians that account for the diversity of racial, ethnic, and sociocultural backgrounds and preferences.

A Telemedicine-Delivered Nursing Intervention for Cancer-Related Distress in Rural Survivors

OBJECTIVES

To evaluate preliminary efficacy, fidelity, and integrity of data collection of a nurse-led, telemedicine-delivered video visit intervention aimed at improving management of rural survivors' cancer-related distress symptoms.

SAMPLE & SETTING

21 rural survivors participated in a nurse-led telemedicine intervention delivered six weeks after the end of active cancer treatment.

METHODS & VARIABLES

Participants' symptom management was measured with the Short Form Survivor Unmet Needs Survey, a four-factor, 30-item instrument that measures the unmet needs of adult survivors. Data were collected preintervention and six weeks postintervention.

RESULTS

The mean difference between pre- and postintervention survey scores was -0.24, representing an overall improvement in management of unmet needs. The unmet emotional needs domain had the highest mean preintervention score and the largest mean reduction. All effect sizes were small.

IMPLICATIONS FOR NURSING

A nurse-led, telemedicine-delivered video visit intervention may improve rural survivors' symptom management during early survivorship. Comparison with a control group using a sample size powered to detect clinically meaningful differences is an important next step to fully evaluate the impact of this model of care.

Statewide Analysis Reveals Period of Well-Child Visit Attendance for Earlier Diagnosis of Autism Spectrum Disorder

OBJECTIVE

To explore the relationship between well-child visit (WCV) attendance during early childhood and age at autism spectrum disorder (ASD) diagnosis using data drawn from a statewide all-payer claims database.

STUDY DESIGN

We used a correlational study design with longitudinal data drawn from the Virginia All-Payer Claims Database. All children born in 2011 with a diagnosis of ASD were included (n = 253). Survival analysis determined the impact of WCV attendance on ASD diagnosis at each American Academy of Pediatrics-recommended early childhood visit, and the 5-year visit.

RESULTS

Survival analysis revealed a significant impact of WCV attendance at the 24-month, 3-, and 4-year visits on earlier ASD diagnosis. Children who attended the 24-month visit were diagnosed nearly 10 months earlier than those who did not. Overall, children with ASD attended fewer than 50% of visits during early childhood.

CONCLUSIONS

Promoting consistent WCV attendance during early childhood is an actionable strategy for improving early identification of ASD. Further exploration is needed to determine barriers to visit attendance and the impact of patterns of early childhood WCV attendance on age of ASD diagnosis. Development and implementation of interventions to promote adherence to the American Academy of Pediatrics-recommended visits is needed.

Spatial analysis of colorectal cancer outcomes and socioeconomic factors in Virginia

BACKGROUND

Colorectal cancer (CRC) disparities vary by country and population group, but often have spatial features. This study of the United States state of Virginia assessed CRC outcomes, and identified demographic, socioeconomic and healthcare access contributors to CRC disparities.

METHODS

County- and city-level cross-sectional data for 2011-2015 CRC incidence, mortality, and mortality-incidence ratio (MIR) were analyzed for geographically determined clusters (hotspots and cold spots) and their correlates. Spatial regression examined predictors including proportion of African American (AA) residents, rural-urban status, socioeconomic (SES) index, CRC screening rate, and densities of primary care providers (PCP) and gastroenterologists. Stationarity, which assesses spatial equality, was examined with geographically weighted regression.

RESULTS

For incidence, one CRC hotspot and two cold spots were identified, including one large hotspot for MIR in southwest Virginia. In the spatial distribution of mortality, no clusters were found. Rurality and AA population were most associated with incidence. SES index, rurality, and PCP density were associated with spatial distribution of mortality. SES index and rurality were associated with MIR. Local coefficients indicated stronger associations of predictor variables in the southwestern region.

CONCLUSIONS

Rurality, low SES, and racial distribution were important predictors of CRC incidence, mortality, and MIR. Regions with concentrations of one or more factors of disparities face additional hurdles to improving CRC outcomes. A large cluster of high MIR in southwest Virginia region requires further investigation to improve early cancer detection and support survivorship. Spatial analysis can identify high-disparity populations and be used to inform targeted cancer control programming.

Improving equitable access to care via telemedicine in rural public libraries

OBJECTIVE

Rural public libraries have been proposed as ideal locations from which individuals can access a telemedicine visit, but limited adoption of this practice suggests significant barriers remain. The purpose of this study was to determine rural public librarians' perspectives on the benefits and barriers to offering patrons the ability to use their public library for a telemedicine video visit, and to suggest strategies for moving this practice forward.

DESIGN

Qualitative content analysis.

SAMPLE

Fifteen rural US librarians and library directors.

MEASUREMENTS

Individual interviews were conducted to determine perspectives on the benefits of and barriers to implementing telemedicine in public libraries.

RESULTS

We identified four themes from the data: rural public libraries increase healthcare access in a trustworthy location, librarians are supportive of telemedicine, but have concerns, limited resources drive barriers to telemedicine implementation in rural libraries, and small rural libraries continued in-person service during the COVID-19 pandemic.

CONCLUSION

Rural public libraries can be an important part of achieving equitable access to care, particularly with regard to chronic disease management in rural populations. Rural public health nurses can be instrumental in promoting collaborations between local libraries and regional health systems that may help libraries overcome financial barriers to this practice.

Delirium Education in Hospice Care: A Quality Improvement Project

Diagnosing delirium in hospice patients is challenging owing to the multifactorial causes and symptoms of delirium that can mimic natural end-of-life processes. When delirium goes unrecognized in hospice patients, preventable causes can be left untreated, leading to sequelae that are misaligned with the principles of hospice care. We conducted an evidence-based quality improvement project on a 10-bed inpatient hospice unit aimed at increasing nursing staff knowledge about assessing delirium, with a focus on preventable causes. Nurses were trained in use of the Nursing Delirium Screening Scale, which was implemented over a 5-week period. Increases in knowledge were evaluated with a pretest and posttest. We used a paired t test to determine knowledge improvement. Use of the tool was evaluated using a survey. Nurses demonstrated significantly improved knowledge after the educational session (P = .009). Survey results indicated overwhelmingly that nurses valued having an easy-to-use tool to assess delirium in their patients. Because we used a paper-based tool during the project, which was found to be cumbersome by staff, our next steps are to determine the feasibility of implementing the tool into the electronic medical record.

Rural Disparities in Early Childhood Well Child Visit Attendance

PURPOSE

Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes.

DESIGN AND METHODS

We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level.

RESULTS

Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance.

CONCLUSIONS

Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.

Use of trajectory models to track air pollution from source to exposure: A methodological approach for identifying communities at risk

OBJECTIVE

Ongoing environmental changes increasingly require public health nurses to understand how environmental factors impact the health of populations. One approach to researching these impacts is incorporating environmental research methods to determine associations between harmful exposures and health. We use the Salton Sea in Southern California as a demonstration of how environmental exposure can be examined using air parcel trajectory analysis.

DESIGN

We demonstrate a methodology for public health nurses to better understand and apply data from the Hybrid Single-Particle Lagrangian Integrated Trajectory meteorological model to estimate the effect of airborne particulate matter from a single source.

MEASUREMENTS

We explain a method for tracking air parcel trajectories to populations: selection of meterological data to identify air parcels, geographic identification of population centers, generation of trajectories, classification of trajectory dispersions, adjusting for atmospheric stability, and merging environmental variables with health data.

CONCLUSIONS

Climate change-related environmental events are expected to become more commonplace and disproportionately affect those populations impacted by health disparities. Public health nurses can identify communities at risk so that public health nursing researchers can use these techniques in collaboration with environmental science to robustly examine health effects of proximal air pollution sources for communities at risk.

Impact of comorbidities and treatment burden on general well-being among women's cancer survivors

BACKGROUND

Gains in cancer detection and treatment have meant that more patients are now living with both cancer and other chronic health conditions, which may become burdensome. We used the Patient Experience with Treatment and Self-Management (PETS) framework to study challenges in self-management and its impact on health among survivors of women's cancers who are caring for other chronic health conditions.

METHODS

Applicability of the PETS domains among survivors of women's cancers with comorbidities was assessed in focus groups to create the study survey. Women surviving primary breast, cervical, ovarian, or endometrial/uterine cancer treated between 6 months and 3 years prior at two large healthcare systems in Virginia were mailed study invitation letters to complete a telephone-based survey. The survey included questions on cancer treatment history, comorbid conditions prior to cancer, treatment and self-management experiences, health literacy, financial security, and items on self-management activities, self-management difficulties and self-management impact (i.e., role/social activity limitations and physical/mental exhaustion). Additionally, general health was assessed with items from the Patient-Reported Outcomes Measurement Information System (PROMIS). Hierarchical regression models and path analysis were used to examine correlates of self-management impact on general physical health (GPH) and mental health (GMH).

RESULTS

Of 1448 patients contacted by mail, 274 (26%) returned an interest form providing their consent to be contacted. Of these, 183 completed the survey. Reasons for non-completion included ineligibility (42), unable to be reached (33) and refusal (6). The majority were survivors of breast (58%) or endometrial/uterine cancer (28%), and 45% resided in non-urban locations. After adjusting for age, race, and cancer type, survivors with higher self-management difficulty reported higher self-management impact, which was associated with lower perceived general health. Reports of higher self-management impact was associated with being single or unmarried, white race, fulltime employed, higher financial insecurity, lower health literacy and more comorbidities. In path analysis, self-management impact was a significant mediator in the association of comorbidity and financial insecurity on GPH and GMH.

CONCLUSIONS

Among survivors of women's cancer, pre-diagnosis comorbidity, health literacy, and financial security are associated with psychosocial impact of self-management and general physical and mental health in the 6 month to 3-year period after cancer treatment has ended. The impact of self-management on psychosocial functioning is an important factor among cancer survivors caring for multiple chronic health conditions. This study provides evidence on the importance of assessing cancer survivors' self-management difficulties such as in future interventions to promote health and wellness.

The Disappearing Lake: A Historical Analysis of Drought and the Salton Sea in the Context of the GeoHealth Framework

The Imperial Valley region of Southeastern California has become one of the most productive agricultural regions in the state and has the highest rates of childhood asthma in California. Lack of precipitation in the Imperial Valley has caused the water level of the Salton Sea to recede to a record low since its formation in the early 1900s. Previous studies of wind and dust deposition conducted in other regions have shown how reduced precipitation, ground heating, and the diminishing water level in an arid climate pose a risk of exposing previously sequestered toxic chemicals to open air, adversely affecting lung health. The purpose of this study is to draw historical parallels between the Aral Sea and Salton Sea in the context of geomorphology, ecology, human health, economics, and human migration, to inform an assessment of environmentally related health impacts of those living in the Imperial Valley region. Future droughts and heatwaves are expected to rise in frequency and severity, disproportionately affecting those impacted by financial and health disparities. Future research must include the implications of population health in the context of GeoHealth as a result of the most recent drought and the receding water levels of the Salton Sea.

Evaluation of rural public libraries to address telemedicine inequities

Access to home-based telemedicine is inequitably distributed in the United States due to the limited reach of fixed broadband in rural areas. Public libraries typically offer patrons free access to broadband. Libraries, particularly those in rural regions, need to be evaluated as sites for patients to connect to a health care provider over a video visit. The purpose of this research was to evaluate the technological readiness of public libraries to provide telemedicine support and to determine differences in readiness between rural and urban public libraries. We distributed a survey to Virginia librarians to evaluate technological readiness of their libraries to support telemedicine. Respondents from 39 libraries completed the survey, approximately one third of which were in rural or small urban areas. All reported fixed broadband, at least four computers, and staff to assist with technology. Eighty-five percent of surveyed libraries reported sufficient broadband speed and a private room available to patrons. There were no significant differences between rural and urban status for any of the library characteristics. Virginia public libraries may have infrastructure necessary to support patrons connecting to telemedicine. Libraries may benefit from systematic guidelines for collaborating with health providers to support telemedicine implementation across geographic and socioeconomically diverse areas.

Mapping Geospatial Gaps in Early Identification of Children With Autism Spectrum Disorder

Despite the known developmental benefits of early intervention for autism spectrum disorder (ASD), diagnosis before age 5 years is often not achieved. Research suggests that lack of health insurance and living in rural areas and areas of severe provider shortages contribute significantly to these delays. The purpose of this project was to conduct a geospatial evaluation of potential gaps in early ASD diagnosis of uninsured children in Virginia. A secondary purpose was to show the use of geospatial analysis by pediatric nurse practitioners for policy advocacy. We mapped data from a statewide provider of ASD evaluative services associated with the Virginia Department of Health and found several communities with high numbers of uninsured children where children may not be receiving early diagnostic services. Pediatric nurse practitioners can help address community-level gaps in early identification of ASD for uninsured young children living in rural areas by conducting outreach programs to providers and families within rural communities and concurrently partnering with nurse-scientists to develop visually impactful geospatial analyses to educate legislators and further advocate for policy positions.

Legislative activity related to the human papillomavirus (HPV) vaccine in the United States (2006-2015): a need for evidence-based policy

State-based policies to mandate HPV vaccination are politically challenging and have received broad criticisms. There is a critical need to understand the legislative activities that underpin subsequent policy implementation. The objective of this policy analysis was to analyze state legislation that focused on HPV vaccination from 2006–2015. A content analysis was conducted among primary sources of legislative data from HPV vaccine-related bills, including using the National Conference of State Legislatures as a search-source. Findings reveal that much of the legislative activity occurred early after the HPV vaccination was introduced, and focused on increased information for parents, public financing, awareness campaigns, etc. Far fewer states focused on voluntary or mandatory vaccination. Understanding the barriers to achieving mandatory vaccination policy and implementation of such policies for HPV vaccines remains a public health priority.

Density and Proximity of Licensed Tobacco Retailers and Adolescent Smoking

Adolescent smoking prevention is an important issue in health care. This literature review describes the theoretical concept of ecological model for adolescent smoking and tobacco retailers and summarizes previous studies on the association between the density and proximity of tobacco retailers and adolescent smoking. We reviewed nine studies on tobacco retailer density and proximity in relation to adolescent smoking, published in peer-reviewed journals between 2004 and 2014. The tobacco retailer density and proximity were correlated with adolescent lifetime smoking, past 12-month smoking, past 30-day smoking, and susceptibility to smoking. School nurses or other school health professionals may need to include the density and proximity of tobacco retailer factors around schools in school-based tobacco-use prevention programs. Health policy makers may need to consider zoning or licensing restrictions of tobacco retailers around schools for adolescent smoking prevention.

Influencing Genomic Change and Cancer Disparities through Neighborhood Chronic Toxic Stress Exposure: A Research Framework

Black Americans have disproportionately higher incidence and mortality rates for many cancers. These disparities may be related to genomic changes that occur from exposure to chronic toxic stress and may result from conditions associated with living in racially segregated neighborhoods with high rates of concentrated poverty. The purpose of this article is to present a nursing research framework for developing and testing neighborhood-level interventions that have the potential to mitigate exposure to neighborhood-associated chronic toxic stress, improve individual-level genomic sequelae and cancer outcomes, and reduce cancer health disparities of Black Americans. Public health nursing researchers should collaborate with local officials to determine ways to reduce neighborhood-level stress. Intermediate outcomes can be measured using genomic or other stress biomarkers, and long-term outcomes can be measured by evaluating population-level cancer incidence and mortality.

Neighborhood: A Conceptual Analysis

Researchers interested in measuring neighborhood-level effects should understand how "neighborhood" is defined within nursing sciences and other sciences, and the inherent strengths and weaknesses of current research methodologies. This concept analysis provides clarity around the concept of neighborhood within the context of health, analyzes the current state of development of the neighborhood concept, and proposes areas for future nursing research. Using the Rodger's Method of analysis, the concept of neighborhood within nursing and public health research is described based on existing literature. The concept's attributes, related concepts, antecedents, and consequences are given from the literature. Comparisons of the use of neighborhood are made between nursing, public health, sociology, and other sciences. The evolution of the concept of neighborhood throughout history is described, and important implications for future research are discussed.

"Civil unrest does not stop ovulation": women's prenatal and family planning services in a 1960s Detroit neighborhood clinic

In 1965, Nancy Milio established a prenatal and family planning clinic in Detroit, Michigan, to address health disparities and limited access to care among low-income, African American, urban women. Women's health disparities persist today nationally and internationally. Using historical methods, this research analyzes how Milio provided women's health services in the context of the social and political environment. Milio empowered neighborhood women to direct, plan, and participate in the care they received. Successful methods to address disparities in access to family and planning and prenatal care should include empowered participation from the women these programs are intending to serve.

Population density, distance to public transportation, and health of women in low-income neighborhoods

OBJECTIVES

The purpose of this research was to determine the impact of two neighborhood walkability (the extent to which the built environment is pedestrian friendly) metrics on health outcomes of women living in low-income urban neighborhoods, both before and after accounting for individual and neighborhood factors.

DESIGN AND SAMPLE

A cross-sectional, retrospective design was used. The sample of 1800 low-income women was drawn from Welfare, Children and Families: A Three-City Study (a study of low-income women from three U.S. cities).

MEASURES

Using multilevel modeling and geographic information systems, the study sought to determine the effect of distance to public transportation and residential density on health status, mental health symptoms, and health-related limitations.

RESULTS

No significant relationship was found between the two walkability metrics and health outcomes. Instead, neighborhood problems that affect crime and safety impacted health status and mental health symptoms.

CONCLUSIONS

As cities make changes to the built environment with the hope of affecting residents' health outcomes, public health nurses need to be aware that changing walkability characteristics in a neighborhood may not affect the health of residents of high crime, low-income neighborhoods. Without first addressing neighborhood crime, efforts to improve walkability in low-income neighborhoods may fail.

Changing health outcomes of vulnerable populations through nursing's influence on neighborhood built environment: a framework for nursing research

PURPOSE

The purpose of this article is to present a framework for nurses to study the impact of built environment on health, particularly in vulnerable populations.

ORGANIZING CONSTRUCT

The framework is adapted from Social Determinants of Health and Environmental Health Promotion, a framework describing how physical and social environments interact to influence individual and population health and health disparities via macro, community-level, and interpersonal factors.

METHODS

The original framework was modified for public health nursing using nursing research evaluating built environment and health, and supplemented with Nightingale's theory of nursing and health.

FINDINGS

The built environment affects health through regional-, neighborhood-, and individual-level factors. Nursing can affect the health of patients by evaluating the neighborhood built environment where patients reside, and by advocating for changes to the built environment.

CONCLUSIONS

Through development of built environment research, nurses can provide valuable insight into the pathways linking built environment to health of vulnerable populations, providing evidence for public health nurses to advocate for these changes on a neighborhood, state, and federal level.

CLINICAL RELEVANCE

This framework can be used by public health clinicians to understand the pathways by which the built environment may be affecting the health of their patients, and by researchers to investigate the pathways, and to design and test community interventions.

Sub-optimal achievement of guideline-derived lipid goals in management of diabetes patients with atherosclerotic cardiovascular disease, despite high use of evidence-based therapies

Guidelines recommend aggressive goals for lipid and blood pressure reduction for high risk patients with diabetes mellitus and atherosclerotic coronary disease. However, it remains unclear how many patients achieve treatment goals versus the number of people merely placed on treatment. We conducted an observational study in an academic cardiology clinic. A total of 926 patients with atherosclerotic cardiovascular disease and concomitant diabetes mellitus met criteria. Mean age was 68.4 ± 10.2, 65.6% were male, and 86.8% were Caucasian. By the last visit a high percentage of patients were receiving recommended medications. Mean LDL-cholesterol achieved was 80.4 mg/dl with 40.9% reaching ≤ 70 mg/dl, and 61.7% reaching SBP ≤ 130 mmHg. Many patients with diabetes mellitus and atherosclerotic cardiovascular disease are prescribed recommended medications; however, few achieve guidelines-specified therapeutic goals for LDL-cholesterol and blood pressure. Studies evaluating performance improvement should include percentage of patients reaching treatment goals. Mechanisms underlying the treatment gap need to be identified and addressed.

Addressing disparities in access to care: lessons from the Kercheval Street clinic in the 1960s

Health disparities for racial and ethnic minorities have been present in the United States and persist today. NMHCs (Nurse-Managed Health Center), which can serve as "Medical Homes," are one mechanism by which nurses can attempt to overcome these disparities within communities. In the mid-1960s, Nancy Milio developed and found funding for a NMHC to address disparities in Detroit, Michigan. History shows that the center was so valued by community members that it remained untouched during the Detroit riot of 1967, despite all buildings surrounding it having been burned down or destroyed. This article uses traditional historic methods to describe the establishment of the center in inner-city Detroit in the 1960s in historical context and analyze factors that led to Milio's success. To address disparities via NMHCs, nurses must be persistent in acquiring funding and should involve a racially and culturally diverse group representative of community members in the development, planning, and ongoing operation of the enterprise.

Abstract P150: Modest Achievement of Guideline-Derived Treatment Goals in Diabetic Patients with Atherosclerotic Cardiovascular Disease Despite High Use of Guideline-Based Therapies

Background: Recent emphasis has been placed on enhancing quality of cardiovascular care using practice guidelines and health information technology to provide feedback to individual physicians. How effective this has been in achieving treatment goals versus percent of appropriate patients receiving guideline-based therapy is unclear. Accordingly, the purpose of this study was to determine how successfully guideline-derived treatment goals were met for outpatients with diabetes (DM) and ASCVD in an academic general cardiology practice with an electronic medical record (EMR).

Methods: A retrospective study was conducted on all outpatients managed in an academic general cardiology clinic who had diagnoses of both ASCVD and DM and had ≥ 2 outpatient visits between January 2008 and September 2009 (n =926), during which time EMR quarterly “report cards” were provided. Values for LDL, HDL, BP and BMI were abstracted for the first and last visits during the study period. Analysis was conducted on the percent of patients achieving treatment goals at each visit and differences in values between first and last visit.

Results: A high percentage of patients were receiving guideline-based drug therapy at their last visit: Statin - 91.0%; Anti-hypertensive, ACE or ARB - 83.4%; Anti-platelet - 92.0%; β-blocker - 75.7%. However, mean LDL at the last visit was 80.4±33.7, and although 81% (649/797) had an LDL-C <= 100 mg/dl, only 41% (326/797) achieved an LDL-C <= 70mg/dl. Similarly, only 61% (563/921) achieved a systolic BP <= 130 mmHg, and mean reduction of BMI between the first and last visit was 1.3% (32.5±11.5 vs. 32.1±9.4, p=NS). The same number of patients gained 10% or more weight during the study period, as lost 10% or more weight, 5.3% (47/886).

Conclusion: A very high percentage of patients were receiving guideline-based drugs, but with respect to achieving ATP III target LDL-C and systolic BP goals, there was less success. The greatest difficulty was in achieving weight loss. These results are similar to those achieved by randomized patients in the BARI-2D trial. In both studies, successful weight loss and achievement of LDL-C guidelines by ATP III were suboptimal although the use of appropriate therapy was high. Additional strategies are needed to achieve these targets.