Toward a Climate-Ready Health Care System: Institutional Motivators and Workforce Engagement

Policy Points The US health care system faces mounting pressure to reduce greenhouse gas emissions and adapt to the impacts of climate change; motivated institutions and an engaged health care workforce are essential to the development, implementation, and maintenance of a climate-ready US health care system. Health care workers have numerous profession-specific and role-specific opportunities to address the causes and impacts of climate change. Policies must address institutional barriers to change and create incentives aligned with climate readiness goals. Institutions and individuals can support climate readiness by integrating content on the health care implications of climate change into educational curricula.

A cross-sectional study to assess faculty and student knowledge of climate change and health: Readiness for curricular integration

AIMS

To examine the perceived knowledge, attitudes and beliefs regarding climate change and health of academic faculty and students in programmes for health professionals and to identify barriers/facilitators to and resources required for curriculum integration.

DESIGN

Cross-sectional survey eliciting quantitative and open-ended responses.

METHODS

A 22-question survey to assess climate-health knowledge/attitudes/beliefs was distributed to all students and faculty (n = 224) at one academic institution in the United States. Open-ended questions addressed barriers, facilitators and required resources. Descriptive statistics are reported, and thematic analysis was used to identify themes from open-ended responses.

RESULTS

Response rate was 15%. Most respondents (76%) were between 20 and 34 years old. The majority were from nursing (39%), occupational therapy (13%) and communication speech disorders (12.5%). Most respondents perceived climate change as relevant to direct patient care (78%) and believed that it is impacting the health of individuals (86%) and should be integrated into curricula (89%). Yet, most (60%) reported modest to no knowledge about the health impacts. Faculty reported little to no comfort teaching climate change and health concepts (76%). Open-ended responses identified student/faculty receptivity and professional/clinical relevance as important facilitators of successful integration. Barriers included intensity of programmes; time and competing curricular priorities; and a lack of faculty expertise, resources, institutional and professional commitment.

CONCLUSIONS

Most health professions students and faculty indicated that educating future health professionals about climate change and health is important, but existing barriers must be addressed.

IMPACT

This study addressed student and faculty perceptions of integrating climate change and health into health professions curricula. Discipline-specific and interprofessional educational approaches are necessary to optimize future health professionals' efforts to prevent and mitigate climate change impacts for at-risk patients, communities and populations.

Health Consequences of Climate Change: Continuing Education Opportunities for Health Professionals in the United States

Climate change is a looming public health challenge. The health consequences of climate change are increasingly recognized as contributing to negative health outcomes for individuals, families, communities, and populations. The education of health professionals in academic programs and continuing education in clinical practice settings is critical in today's world. The Association of American Medical Colleges and the National League for Nursing, among other organizations, have urged academic programs to include the impact of climate change on health in health professions education and have started to integrate it into curricula. However, health professionals educated over the past several decades have received little content related to the deleterious impact of climate change on health. Therefore, continuing education programs addressing the health consequences of climate change are being developed to fill the gap in health professions education globally. This review study explicated the available continuing education opportunities for public health professionals and health care providers related to the health consequences of climate change. [J Contin Educ Nurs. 2023;54(12):561-566.].

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.

Leadership in Nursing Education for Advancing a School of Nursing-Led Center for Climate Change, Climate Justice, and Health

BACKGROUND

This article examines innovations in the development and advancement of a school of nursing-led climate change center and innovative leadership related to climate change and health in nursing education.

METHOD

The integration of health consequences of climate change in curricula and continuing education is essential to prepare nursing students and nurses for clinical practice.

RESULTS

Transformational leadership is a key concept for effective leadership in nursing education to address climate change as the looming public health challenge of the 21st century. Transformational leadership strengthened one nursing program's curricula, dissemination of relevant scholarship, and achievements with public health outreach related to climate change, climate justice, and health.

CONCLUSION

Nursing education leaders can influence nursing practice and improve societal health outcomes related to the health consequences of climate change across all levels of education and continuing education for professional nurses. [J Nurs Educ. 2023;62(9):528-531.].

The Future of Nursing 2020-2030: The Critical Role of Nurses and Nurse Leaders in Addressing the Health Impacts of Climate Change

Climate change represents a looming health challenge and a critical area for nursing leadership at all levels of organizations and settings. With a lens on The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, addressing climate change-related health consequences should be a major focus and spotlight for nurses and nurse leaders with a lens on individuals, communities, populations, and from a national and global perspective.

Development of a screening tool for assessment of climate change-related heat illness in the clinical setting

ABSTRACT

Extreme heat contributes to heat-related illnesses resulting from heat intolerance, which is the inability to maintain a thermal balance to tolerate heat stress. In the United States, heat-related mortality for older persons has almost doubled in the past 20 years. Other populations at risk for heat-related illness (HRI) include children, pregnant people, those who work outside, young people participating in outdoor sports, and at-risk populations such as Black, indigenous, and populations of color. The classic heat tolerance test used for decades monitoring physiological responses to repetitive motions is impractical across large and potentially health challenged populations and does not identify environmental or social factors or specific vulnerable populations. To address this issue, we developed a heat-related illness screening tool (HIST) to identify individuals at risk for HRI morbidity and mortality based on their physical, environmental, and social vulnerabilities with an emphasis on populations of concern. The HIST has the potential to be used as routine clinical screening in the same way as other commonly used screening tools. Heat intolerance affects patient outcomes and quality of life; therefore, early screening with a simple, easy-to-administer screening tool such as the HIST can identify people at risk and refer them to services that address heat exposure and/or create safety nets to prevent heat-related illnesses.

Occupational Heat Stress: An Overview for Nurse Practitioners

ABSTRACT

The health impacts of climate change are pervasive and complex. The role of nurse practitioners is a key in addressing these emerging health challenges. However, few health care providers are aware of the extensive signs and symptoms that accompany climate-related health sequelae. This article explores the increasing prevalence of occupational heat stress and best practices for nurse practitioners in addressing this problem. The A CLIMATE mnemonic is a clinical tool applied to occupational heat stress and aims to address a comprehensive health assessment and proactive management. Two clinical case studies will be offered as exemplars of occupational heat stress. The cases are framed within the A CLIMATE mnemonic for health assessment and physical examination for nurse practitioner practice.

Health impacts of climate change on gender diverse populations: A scoping review

PURPOSE

To determine what is known about climate change health effects for gender diverse (GD) populations, and identify gaps in research, practice, education, and policy.

DESIGN/METHODS

A scoping review was conducted.

FINDINGS

Twenty-seven information sources met inclusion criteria. Natural disasters and inadequate disaster relief responses were identified as an overarching health threat for GD populations. Within this theme, four sub-themes emerged. No other climate-related health impacts for GD populations were mentioned in the sources reviewed.

CONCLUSIONS

There are major gaps in knowledge about health implications of climate change for GD populations. Gender-sensitive data must be collected in order to better understand these threats and detect disparities. Currently most practice and policy recommendations focus on disaster relief. More research on the broad effects of climate change on GD populations is urgently needed to inform practice and policy.

CLINICAL RELEVANCE

Climate change amplifies existing risks of adverse health outcomes. Because of discrimination, stigma, and violence, gender diverse individuals are particularly vulnerable.

The intersection of climate change with the era of COVID-19

The purpose of this integrative review is to examine recent literature on the intersection of SARS-CoV-2 (COVID-19 novel coronavirus) and climate change that will lead to a greater understanding of the complexities of the urgent pandemic linked with the emerging climate crisis. A literature search for peer-reviewed, English language, literature published since the pandemic emerged was conducted using Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed, and the Cochrane Library. The final sample yielded a total of 22 commentaries, editorials, discussion papers, and a research study that explicitly addressed the intersection of COVID-19 and climate change. Sixty articles emerged in the initial review of the intersection of the COVID-19 pandemic and climate change with the final yield of 22 articles deemed valid for inclusion after full text review. With the emergence of COVID-19 and scholarly discourse that addresses the intersection of the pandemic with climate change, key issues emerged that intersect with policy /advocacy, social justice, and nursing's public health role in clinical practice, education, policy/advocacy, and research/scholarship. Five themes that emerged included the role of public health in COVID-19 and climate change efforts; global approach addressing human-environment issues; intersection of COVID-19 and climate change from a community and global perspective; impacts of COVID-19, climate change and the environment and professional associations and specialty organizations' views and responsibilities with a lens on COVID-19 and climate change. Despite the importance of addressing racial inequities as well as systemic and structural racism that impacts those most affected by climate change and pandemics such as COVID-19, no literature addressed this topic. Public health nursing has a critical role in addressing climate change and the pandemic response to COVID 19 in the 21st century.

A CLIMATE: A Tool for Assessment of Climate-Change-Related Health Consequences in the Emergency Department

Climate change is an urgent public health problem that has looming implications and associated deleterious health consequences. The intersection of climate change and health has broad implications for health professionals in a variety of settings but especially for ED settings. Climate change is already affecting human health and health systems-which includes impacts on ED care. Disaster response and emergency preparedness are critically important public health interventions in our climate-changing world, and the contributions of emergency nurses are essential. Disaster preparedness, environmental emergency response, and health emergency management are important elements of emergency nursing and are explicated in Sheehy's Emergency Nursing Principles and Practices, 7th Edition. The purpose of this article is to present an overview of a clinical tool and mnemonic, A CLIMATE, developed by the authors with application to a case review. It is imperative that the nursing profession-particularly emergency clinicians-address the intersection of climate and health to engage in the assessment, intervention, management, evaluation, education, and referral of those who present to emergency departments with potential climate-related health impacts.

Climate Change and Population Health: Incorporating Stages of Nursing's Political Development

Climate change is the greatest public health threat of the 21^st century and is associated with environmental degradation and deleterious health consequences. In 2019, the Lancet Commission Report on Health and Climate Change: Ensuring that the Health of a Child Born Today Is Not Defined By a Changing Climate (Watts et al., 2019) examined the critical health issues that children will face in the era of climate change. Greenhouse gas emissions (GGEs) are responsible for an alarming increase in the warming of the planet, shifts in weather patterns, loss of arable land, and exacerbations of acute health issues, chronic health problems, and disaster-related health consequences. The purpose of this paper is to provide an overview of climate change and the associated deleterious health consequences in our climate-changing world. The paper will also examine the stages of political development to advance the 21^st century role of the nursing profession in climate and health advocacy and policy.

Integrating Climate Change Topics Into Nursing Curricula

BACKGROUND

Health professionals have a key role in addressing the health impacts of climate change at several levels: direct patient care, client and community education, health professions education, and through advocacy and health policy development.

METHOD

Recognizing that nurses are the first line in health education, nursing faculty at the MGH Institute of Health Professions developed the first nurse-led Center for Climate Change, Climate Justice and Health (CCCCJH).

RESULTS

A steering committee of nurse climate change scholars and interested faculty developed a mission, vision, core values, and a strategic plan for the CCCCJH and are working on integrating climate change topics into nursing curricula at all levels.

CONCLUSION

Nurses are in the ideal position to lead the way to increase awareness among health professionals and students about the health impacts of climate change. Curricular integration of climate change topics at all levels will prepare our students to meet the needs and challenges of the future. [J Nurs Educ. 2019;58(6):364-368.].

Advancing a School of Nursing Center for Climate Change, Climate Justice, and Health

This chapter addresses the development and advancement of the Center for Climate Change, Climate Justice, and Health (CCCCJH) in the School of Nursing at the MGH Institute of Health Professions, the first nurse-led center emerged from the overwhelming evidence of climate change and its associated deleterious health consequences. The Center steering committee developed a mission, vision, and core values as well as a logo to guide the first year of initiatives and galvanize the efforts for the future. Workshop and symposium development, implementation, and evaluation are discussed. Future directions and the importance of educational initiatives aimed at expanding nursing and interprofessional knowledge of the intersection of climate and health are discussed.

Health Literacy and Health Outcomes in Persons Living with HIV Disease: A Systematic Review

Low health literacy is associated with challenges for those living with HIV including medication non-adherence and poorer health outcomes. The aim of this study was to systematically review the literature on health literacy and health outcomes in persons living with HIV. The extended guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, as well as A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist were utilized to guide the approach to the review. A variety of electronic databases including PubMed, CINAHL, PsychInfo, and Cochrane Library were searched. Additional literature available on U.S. government websites was also included in the search. Search terms were used in a variety of combinations and included HIV, health literacy, adherence, and health outcomes. Forty-eight studies were identified that addressed health literacy and health outcomes in HIV. Although several studies in this review did not provide robust results of statistical significance linking health literacy with health outcomes, all of the studies addressed the key significance of health literacy within the scope of living with HIV disease. The relationship between health literacy and the identified health outcomes requires further research and explication.

Use of Dolutegravir for Antiretroviral Therapy for Women of Childbearing Age

The purpose of this article is to offer an update on the use of antiretroviral therapy (ART) for HIV among women of childbearing age. We focus specifically on the use of dolutegravir (DTG) because of a recently identified potential safety issue related to neural tube defects in the fetuses of women who used DTG at the time of conception. Nurses and advanced practice registered nurses should engage in shared decision-making processes for reproductive life planning with women of childbearing age who are living with or are at risk for HIV. During these processes, exploration of the full range of ART regimens is essential. Consistent and reliable contraception is necessary with the use of DTG because it is not recommended in the first trimester of pregnancy.

A qualitative description of service providers' experiences of ethical issues in HIV care

BACKGROUND

Managing HIV treatment is a complex multi-dimensional task because of a combination of factors such as stigma and discrimination of some populations who frequently get infected with HIV. In addition, patient-provider encounters have become increasingly multicultural, making effective communication and provision of ethically sound care a challenge.

PURPOSE

This article explores ethical issues that health service providers in the United States and Botswana encountered in their interaction with patients in HIV care.

RESEARCH DESIGN

A descriptive qualitative design was used to collect data from health service providers and patients using focused group discussions. This article is based on responses from health service providers only.

PARTICIPANTS AND CONTEXT

This article is based on 11 focused group discussions with a total sample of 71 service providers in seven US sites and one Botswana site.

ETHICAL CONSIDERATIONS

Ethical review boards at all the study sites reviewed the study protocol and approved it. Ethical review boards of the study's coordinating centers, Rutgers University and the University of California at San Francisco, also approved it. The study participants provided a written informed consent to participate.

FINDINGS

HIV service providers encountered ethical challenges in all the four Beauchamp and Childress' biomedical ethics of respect for patients' autonomy, beneficence, justice, and nonmaleficence.

DISCUSSION

The finding that HIV service providers encounter ethical challenges in their interaction with patients is supported by prior studies. The ethical challenges are particularly prominent in multicultural care and resource-constrained care environments.

CONCLUSION

Provision of HIV care is fraught with ethical challenges that tend to pose different issues depending on a given care environment. It is important that strong partnerships are developed among key stakeholders in HIV care. In addition, health service providers need to be provided with resources so they can provide quality and ethically sound care.

Mandate for the Nursing Profession to Address Climate Change Through Nursing Education

PURPOSE

The adverse health effects from climate change demand action from the nursing profession. This article examines the calls to action, the status of climate change in nursing education, and challenges and recommendations for nursing education related to climate change and human health.

ORGANIZING CONSTRUCT

Discussion paper.

FINDINGS

The integration of climate change into nursing education is essential so that knowledge, skills, and insights critical for clinical practice in our climate-changing world are incorporated in curricula, practice, research, and policy. Our Ecological Planetary Health Model offers a framework for nursing to integrate relevant climate change education into nursing curricula and professional nursing education. Nursing education can offer a leadership role to address the mitigation, adaptation, and resilience strategies for climate change.

CONCLUSIONS

An ecological framework is valuable for nursing education regarding climate change through its consideration of political, cultural, economic, and environmental interrelationships on human health and the health of the planet. Knowledge of climate change is important for integration into basic and advanced nursing education, as well as professional education for nurses to address adverse health impacts, climate change responses policy, and advocacy roles.

CLINICAL RELEVANCE

For current and future nurses to provide care within a climate-changing environment, nursing education has a mandate to integrate knowledge about climate change issues across all levels of nursing education. Competence in nursing practice follows from knowledge and skill acquisition gained from integration of climate change content into nursing education.

A multinational qualitative investigation of the perspectives and drivers of exercise and dietary behaviors in people living with HIV

Globally, people living with HIV (PLWH) are at remarkably high risk for developing chronic comorbidities. While exercise and healthy eating reduce and mitigate chronic comorbidites, PLWH like many others, often fail to engage in recommended levels. We qualitatively examined the perspectives and contextual drivers of diet and exercise reported by PLWH and their health care providers. Two hundred and six participants across eight sites in the United States, Puerto Rico and Botswana described one overarching theme, Arranging Priorities, and four subthemes Defining Health, Perceived Importance of Diet and Exercise, Competing Needs, and Provider Influence. People living with HIV and their health care providers recognize the importance of eating a healthy diet and engaging in regular exercise. Yet there are HIV-specific factors limiting these behaviors that should be addressed. Health care providers have an important, and often underutilized opportunity to support PLWH to make improvements to their exercise and diet behavior.

90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies

Medication adherence is the "Plus" in the global challenge to have 90% of HIV-infected individuals tested, 90% of those who are HIV positive treated, and 90% of those treated achieve an undetectable viral load. The latter indicates viral suppression, the goal for clinicians treating people living with HIV (PLWH). The comparative importance of different psychosocial scales in predicting the level of antiretroviral adherence, however, has been little studied. Using data from a cross-sectional study of medication adherence with an international convenience sample of 1811 PLWH, we categorized respondent medication adherence as None (0%), Low (1-60%), Moderate (61-94%), and High (95-100%) adherence based on self-report. The survey contained 13 psychosocial scales/indices, all of which were correlated with one another (p < 0.05 or less) and had differing degrees of association with the levels of adherence. Controlling for the influence of race, gender, education, and ability to pay for care, all scales/indices were associated with adherence, with the exception of Berger's perceived stigma scale. Using forward selection stepwise regression, we found that adherence self-efficacy, depression, stressful life events, and perceived stigma were significant predictors of medication adherence. Among the demographic variables entered into the model, nonwhite race was associated with double the odds of being in the None rather than in the High adherence category, suggesting these individuals may require additional support. In addition, asking about self-efficacy, depression, stigma, and stressful life events also will be beneficial in identifying patients requiring greater adherence support. This support is essential to medication adherence, the Plus to 90-90-90.

Language and Culture in Health Literacy for People Living with HIV: Perspectives of Health Care Providers and Professional Care Team Members

Low health literacy has been linked to inadequate engagement in care and may serve as a contributor to poor health outcomes among people living with HIV and AIDS. The purpose of this paper was to examine the perspectives of health care providers and professional care team members regarding health literacy in HIV disease. A secondary data analysis was conducted from a qualitative study aimed at understanding factors that help an HIV positive person to manage their HIV disease. Data were collected from sites in Botswana, the US, and Puerto Rico. In the parent study, data were collected through focus group discussions with 135 people living with HIV, 32 HIV health care providers (HCPs), and 39 HIV professional care team members (PCTMs). SPSS was used to analyze quantitative data while ATLAS.ti was used to analyze qualitative data. The findings from analyses of the perspectives of HCPs/PCTMs suggested that linguistic and cultural factors were important themes in the exchange of HIV information between health care providers and PLHIV. These themes included ineffective communication, health seeking behavior, cultural facilitators, and complementary and alternative/traditional healing methods. Thus, this study suggests that language and culture have a major role in health literacy for PLHIV.

Building Trust and Relationships Between Patients and Providers: An Essential Complement to Health Literacy in HIV Care

Health literacy is important for access to and quality of HIV care. While most models of health literacy acknowledge the importance of the patient-provider relationship to disease management, a more nuanced understanding of this relationship is needed. Thematic analysis from 28 focus groups with HIV-experienced patients (n = 135) and providers (n = 71) identified a long-term and trusting relationship as an essential part of HIV treatment over the continuum of HIV care. We found that trust and relationship building over time were important for patients with HIV as well as for their providers. An expanded definition of health literacy that includes gaining a patient's trust and engaging in a process of health education and information sharing over time could improve HIV care. Expanding clinical perspectives to include trust and the importance of the patient-provider relationship to a shared understanding of health literacy may improve patient experiences and engagement in care.

Self-compassion and risk behavior among people living with HIV/AIDS

Sexual risk behavior and illicit drug use among people living with HIV/AIDS (PLWHA) contribute to poor health and onward transmission of HIV. The aim of this collaborative multi-site nursing research study was to explore the association between self-compassion and risk behaviors in PLWHA. As part of a larger project, nurse researchers in Canada, China, Namibia, Puerto Rico, Thailand and the US enrolled 1211 sexually active PLWHA using convenience sampling. The majority of the sample was male, middle-aged, and from the US. Illicit drug use was strongly associated with sexual risk behavior, but participants with higher self-compassion were less likely to report sexual risk behavior, even in the presence of illicit drug use. Self-compassion may be a novel area for behavioral intervention development for PLWHA.

Peripheral neuropathy in HIV: an analysis of evidence-based approaches

Peripheral neuropathy is a common and vexing symptom for people living with HIV infection (PLWH). Neuropathy occurs in several different syndromes and is identified in the literature as distal sensory polyneuropathy or distal sensory peripheral neuropathy. More recently, the HIV literature has focused on the syndrome as painful HIV-associated sensory neuropathy, addressing the symptom rather than the underlying pathophysiology. Assessment of neuropathy in PLWH is critical and must be incorporated into nursing practice for each visit. Neuropathy has been attributed to the direct effects of HIV, exposure to antiretroviral medications (particularly the nucleoside reverse transcriptase inhibitors), advanced immune suppression, and comorbid tuberculosis infection and exposure to antituberculosis medications. Evidence supports the importance of addressing neuropathy in PLWH with pharmacologic treatment regimens and complementary/alternative approaches. This paper examines the pathophysiology, evidence, and approaches to managing peripheral neuropathy. A case study has been included to illustrate a patient's experience with neuropathy symptoms.

Depressive symptoms, self-esteem, HIV symptom management self-efficacy and self-compassion in people living with HIV

The aims of this study were to examine differences in self-schemas between persons living with HIV/AIDS with and without depressive symptoms, and the degree to which these self-schemas predict depressive symptoms in this population. Self-schemas are beliefs about oneself and include self-esteem, HIV symptom management self-efficacy, and self-compassion. Beck's cognitive theory of depression guided the analysis of data from a sample of 1766 PLHIV from the USA and Puerto Rico. Sixty-five percent of the sample reported depressive symptoms. These symptoms were significantly (p ≤ 0.05), negatively correlated with age (r = -0.154), education (r = -0.106), work status (r = -0.132), income adequacy (r = -0.204, self-esteem (r = -0.617), HIV symptom self-efficacy (r = - 0.408), and self-kindness (r = - 0.284); they were significantly, positively correlated with gender (female/transgender) (r = 0.061), white or Hispanic race/ethnicity (r = 0.047) and self-judgment (r = 0.600). Fifty-one percent of the variance (F = 177.530 (df = 1524); p < 0.001) in depressive symptoms was predicted by the combination of age, education, work status, income adequacy, self-esteem, HIV symptom self-efficacy, and self-judgment. The strongest predictor of depressive symptoms was self-judgment. Results lend support to Beck's theory that those with negative self-schemas are more vulnerable to depression and suggest that clinicians should evaluate PLHIV for negative self-schemas. Tailored interventions for the treatment of depressive symptoms in PLHIV should be tested and future studies should evaluate whether alterations in negative self-schemas are the mechanism of action of these interventions and establish causality in the treatment of depressive symptoms in PLHIV.

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America

BACKGROUND

Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one's life chances and overcome life's challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH.

METHODS

We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations.

RESULTS

Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence.

CONCLUSIONS

Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society's most vulnerable populations.

Use of a brief version of the self-compassion inventory with an international sample of people with HIV/AIDS

The objective of this study was to extend the psychometric evaluation of a brief version of the Self-Compassion Scale (SCS). A secondary analysis of data from an international sample of 1967 English-speaking persons living with HIV disease was used to examine the factor structure, and reliability of the 12-item Brief Version Self-Compassion Inventory (BVSCI). A Maximum Likelihood factor analysis and Oblimin with Kaiser Normalization confirmed a two-factor solution, accounting for 42.58% of the variance. The BVSCI supported acceptable internal consistencies, with 0.714 for the total scale and 0.822 for Factor I and 0.774 for Factor II. Factor I (lower self-compassion) demonstrated strongly positive correlations with measures of anxiety and depression, while Factor II (high self-compassion) was inversely correlated with the measures. No significant differences were found in the BVSCI scores for gender, age, or having children. Levels of self-compassion were significantly higher in persons with HIV disease and other physical and psychological health conditions. The scale shows promise for the assessment of self-compassion in persons with HIV without taxing participants, and may prove essential in investigating future research aimed at examining correlates of self-compassion, as well as providing data for tailoring self-compassion interventions for persons with HIV.

The impact of stressful life events, symptom status, and adherence concerns on quality of life in people living with HIV

Studies concerning persons living with HIV (PLWH) report that stressful life events (SLEs) contribute to an exacerbation of symptoms and reduced antiretroviral (ARV) adherence and quality of life (QOL). Little is known about whether these findings are site-specific. Our study's aims were to characterize the type and frequency of SLEs for PLWH in Puerto Rico, South Africa, and the United States, and to assess the impact of SLEs by national site, symptoms, and ARV adherence concerns on QOL. The sample consisted of 704 participants. The total number of SLEs correlated significantly with the total number of symptoms, adherence concerns, and QOL (p ≤ .001). Overall, 27.2% of the variance in QOL was explained by the aforementioned variables. Although SLEs were of concern to PLWH, worries about ARV adherence were of even greater concern. Routine assessment of ARV concerns and SLEs can promote ongoing ARV adherence and improved QOL.

A randomized controlled trial of an HIV/AIDS Symptom Management Manual for depressive symptoms

Abstract Depressive symptoms are highly prevalent, underdiagnosed, and undertreated in people living with HIV/AIDS (PLWH), and are associated with poorer health outcomes. This randomized controlled trial examined the effects of the HIV/AIDS Symptom Management Manual self-care symptom management strategies compared with a nutrition manual on depressive symptoms in an international sample of PLWH. The sample consisted of a sub-group (N=222) of participants in a larger study symptom management study who reported depressive symptoms. Depressive symptoms of the intervention (n=124) and control (n=98) groups were compared over three months: baseline, one-month, and two-months. Use and effectiveness of specific strategies were examined. Depressive symptom frequency at baseline varied significantly by country (χ (2) 12.9; p=0.04). Within the intervention group there were significant differences across time in depressive symptom frequency [F(2, 207) = 3.27, p=0.05], intensity [F(2, 91) = 4.6, p=0.01], and impact [F(2, 252) = 2.92, p= 0.05), and these were significantly lower at one month but not at two months, suggesting that self-care strategies are effective in reducing depressive symptoms, however effects may be short term. Most used and most effective self-care strategies were distraction techniques and prayer. This study suggests that people living with HIV can be taught and will employ self-care strategies for management of depressive symptoms and that these strategies are effective in reducing these symptoms. Self-care strategies are noninvasive, have no side-effects, and can be readily taught as an adjunct to other forms of treatment. Studies are needed to identify the most effective self-care strategies and quantify optimum dose and frequency of use as a basis for evidence-based practice.

Mediators of antiretroviral adherence: a multisite international study

The purpose of this study was to investigate the effects of stressful life events (SLE) on medication adherence (3 days, 30 days) as mediated by sense of coherence (SOC), self-compassion (SCS), and engagement with the healthcare provider (eHCP) and whether this differed by international site. Data were obtained from a cross-sectional sample of 2082 HIV positive adults between September 2009 and January 2011 from sites in Canada, China, Namibia, Puerto Rico, Thailand, and US. Statistical tests to explore the effects of stressful life events on antiretroviral medication adherence included descriptive statistics, multivariate analysis of variance, analysis of variance with Bonferroni post-hoc analysis, and path analysis. An examination by international site of the relationships between SLE, SCS, SOC, and eHCP with adherence (3 days and 30 days) indicated these combined variables were related to adherence whether 3 days or 30 days to different degrees at the various sites. SLE, SCS, SOC, and eHCP were significant predictors of adherence past 3 days for the United States (p = < 0.001), Canada (p = 0.006), and Namibia (p = 0.019). The combined independent variables were significant predictors of adherence past 30 days only in the United States and Canada. Engagement with the provider was a significant correlate for antiretroviral adherence in most, but not all, of these countries. Thus, the importance of eHCP cannot be overstated. Nonetheless, our findings need to be accompanied by the caveat that research on variables of interest, while enriched by a sample obtained from international sites, may not have the same relationships in each country.

Exploring the contribution of general self-efficacy to the use of self-care symptom management strategies by people living with HIV infection

General self-efficacy (GSE), the expectation that one is able to perform a behavior successfully, may differentiate those who are able to successfully utilize self-care symptom management strategies (SCSMS). This subanalysis (n=569) of an international 12 site longitudinal randomized controlled trial (RCT) (n=775), investigated GSE as an important factor determining symptom burden, SCSMS, engagement with the provider, and medication adherence over time, and identified differences in those with high and low GSE ratings concerning these variables. Parametric and nonparametric repeated-measures tests were employed to assess GSE and the perceived effectiveness of SCSMS for anxiety, depression, diarrhea, fatigue, nausea, and neuropathy. Symptom burden, engagement with the provider, and antiretroviral adherence were analyzed with regard to GSE. Our data indicated that there were differences in the perceived symptom burden over time of HIV infected individuals by GSE. Those individuals with higher GSE had fewer symptoms and these symptoms were perceived to be less intense than those experienced by the low GSE group. There were few meaningful differences in the SCSMS used by those with high versus low GSE other than the use of illicit substances in the low GSE group. The low GSE group was also significantly (p= < 0.001) less engaged with their healthcare providers. Given the difference in substance use by perceived GSE, and the importance of engagement with the healthcare provider, more attention to the resolution of the concerns of those with low GSE by healthcare providers is warranted.

Unhealthy substance-use behaviors as symptom-related self-care in persons with HIV/AIDS

Unhealthy substance-use behaviors, including a heavy alcohol intake, illicit drug use, and cigarette smoking, are engaged in by many HIV-positive individuals, often as a way to manage their disease-related symptoms. This study, based on data from a larger randomized controlled trial of an HIV/AIDS symptom management manual, examines the prevalence and characteristics of unhealthy behaviors in relation to HIV/AIDS symptoms. The mean age of the sample (n = 775) was 42.8 years and 38.5% of the sample was female. The mean number of years living with HIV was 9.1 years. The specific self-reported unhealthy substance-use behaviors were the use of marijuana, cigarettes, a large amount of alcohol, and illicit drugs. A subset of individuals who identified high levels of specific symptoms also reported significantly higher substance-use behaviors, including amphetamine and injection drug use, heavy alcohol use, cigarette smoking, and marijuana use. The implications for clinical practice include the assessment of self-care behaviors, screening for substance abuse, and education of persons regarding the self-management of HIV.

Prevalence, correlates, and self-management of HIV-related depressive symptoms

Depressive symptoms are highly prevalent yet undertreated in people living with HIV/AIDS (PLHAs). As part of a larger study of symptom self-management (N=1217), this study examined the prevalence, correlates, and characteristics (intensity, distress, and impact) of depressive symptoms, and the self-care strategies used to manage those symptoms in PLHAs in five countries. The proportion of respondents from each country in the total sample reporting depressive symptoms in the past week varied and included Colombia (44%), Norway (66%), Puerto Rico (57%), Taiwan (35%), and the USA (56%). Fifty-four percent (n=655) of the total sample reported experiencing depressive symptoms in the past week, with a mean of 4.1 (SD 2.1) days of depression. Mean depression intensity 5.4 (SD 2.7), distressfulness 5.5 (SD 2.86), and impact 5.5 (SD 3.0) were rated on a 1-10 scale. The mean Center for Epidemiologic Studies Depression Scale score for those reporting depressive symptoms was 27 (SD 11; range 3-58), and varied significantly by country. Respondents identified 19 self-care behaviors for depressive symptoms, which fell into six categories: complementary therapies, talking to others, distraction techniques, physical activity, medications, and denial/avoidant coping. The most frequently used strategies varied by country. In the US sample, 33% of the variance in depressive symptoms was predicted by the combination of education, HIV symptoms, psychological and social support, and perceived consequences of HIV disease.

Exploring the patterns of use and the feasibility of using cellular phones for clinic appointment reminders and adherence messages in an antiretroviral treatment clinic, Durban, South Africa

In preparation for a proposed intervention at an antiretroviral therapy (ART) clinic in Durban, South Africa, we explored the dynamics and patterns of cellular phone use among this population, in order to ascertain whether clinic contact via patients' cellular phones was a feasible and acceptable modality for appointment reminders and adherence messages. Adults, who were more than 18 years old, ambulatory, and who presented for treatment at the clinic between October-December 2007, were consecutively recruited until the sample size was reached (n = 300). A structured questionnaire was administered, including questions surrounding sociodemographics, cellular phone availability, patterns of use, and acceptability of clinic contact for the purpose of clinic appointment reminders and adherence support. Most respondents (n = 242; 81%) reported current ownership of a cellular phone with 95% utilizing a prepaid airtime service. Those participants who currently owned a cellular phone reported high cellular phone turnover due to theft or loss (n = 94, 39%) and/or damage (n = 68, 28%). More females than men switched their cell phones off during the day (p = 0.002) and were more likely to not take calls in certain social milieus (p ≤ 0.0001). Females were more likely to share their cell phone with others (p = 0.002) or leave it in a place where someone could access it (p = 0.005). Most respondents were willing to have clinic contact via their cellular phones, either verbally (99%) or via text messages (96%). The use of cellular phones for intervention purposes is feasible and should be further investigated. The findings highlight the value of gender-based analyses in informing interventions.

Prevalence, self-care behaviors, and self-care activities for peripheral neuropathy symptoms of HIV/AIDS

As part of a larger randomized controlled trial examining the efficacy of an HIV/AIDS symptom management manual (n = 775), this study examined the prevalence of peripheral neuropathy in HIV-infected individuals at 12 sites in the USA, Puerto Rico, and Africa. Neuropathy was reported by 44% of the sample; however, only 29.4% reported initiating self-care behaviors to address the neuropathy symptoms. Antiretroviral therapy was found to increase the frequency of neuropathy symptoms, with an increased mean intensity of 28%. A principal axis factor analysis with Promax rotation was used to assess the relationships in the frequency of use of the 18 self-care activities for neuropathy, revealing three distinct factors: (i) an interactive self-care factor; (ii) a complementary medicine factor; and (iii) a third factor consisting of the negative health items of smoking, alcohol, and street drugs. The study's results suggest that peripheral neuropathy is a common symptom and the presence of neuropathy is associated with self-care behaviors to ameliorate HIV symptoms. The implications for nursing practice include the assessment and evaluation of nursing interventions related to management strategies for neuropathy.

HIV and tuberculosis in Durban, South Africa: adherence to two medication regimens

Given that antiretroviral (ARV) medication adherence has been shown to be high in resource-limited countries, the question remains as to whether adherence will remain at that level as medications become more widely available. Comparing adherence to tuberculosis (TB) medications, which have been readily available, and ARV medications may help to indicate the likely future adherence to ARVs as access to these medications becomes more widespread. This study examined sense of coherence, social support, symptom status, quality of life, and adherence to medications in two samples of individuals being treated either for TB or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) at clinics in Durban, South Africa. Findings revealed the distinctive socio-economic backgrounds of the two cohorts. Although there were significant differences with regard to the psychosocial variables, there were no significant differences by the two samples in adherence to medications as well as adherence to appointments. Given the self-selected nature of the participants in this study, namely those able to attend clinic, as well as those likely to be adherent to ARVs, there is every reason for caution in the interpretations of these findings. As access to ARV medications becomes more widely available in South Africa, the question remains as to whether such high adherence will be maintained given the constraints of access to food and other basic necessities.

Exploring HIV stigma and quality of life for persons living with HIV infection

The purpose of this study was to explore the potential contribution of perceived HIV stigma to quality of life for people living with HIV infection. A cross-sectional design explored the contribution of demographic variables, symptoms, and stigma to quality of life in an international sample of 726 people living with HIV infection. Stigma independently contributed a significant 5.3% of the explained variance in quality of life, after removing contributions of HIV-related symptoms and severity of illness. This study empirically documents that perceived HIV stigma had a significantly negative impact upon quality of life for a broad sample of people living with HIV infection.

Marijuana effectiveness as an HIV self-care strategy

Persons living with HIV/AIDS use self-care for symptom management. This study assesses the use of marijuana as a symptom management approach for six common symptoms for persons living with HIV/AIDS--anxiety, depression, fatigue, diarrhea, nausea, and peripheral neuropathy. This sub-analysis of the efficacy of a symptom management manual encompasses the experiences of participants from sites in the U.S., Africa, and Puerto Rico. Baseline data are analyzed to examine differences in the use and efficacy of marijuana as compared with prescribed and over-the-counter medications as well as the impact on adherence and quality of life.

Quality of life and physical functioning in HIV-infected individuals receiving antiretroviral therapy in KwaZulu-Natal, South Africa

KwaZulu-Natal province, South Africa, accounts for 28.7% of the HIV infection total and one-third of infections among youth and children in South Africa. The purpose of this study was to examine the variables of HIV/AIDS symptoms, social support, influence of comorbid medical problems, length of time adhering to antiretroviral therapy medications, quality of life, adherence to antiretroviral medications, and physical functioning in HIV-infected individuals. Based on our model, the combination of these variables was found to determine physical functioning outcomes and adherence to HIV medications. Significant relationships were observed between physical functioning and the dependent variables of length of time on medications, comorbid health problems, and social support. A linear regression model was built to determine the degree to which these variables predicted physical functioning. In total, these predictor variables explained 29% of the variance in physical functioning. These results indicate that those individuals who reported a greater length of time on medications, fewer comorbid health problems, and greater social support had better physical functioning.

Social responsibility of nursing: a global perspective

This study addresses social responsibility in the discipline of nursing and implications for global health. The concept of social responsibility is explicated and its relevance for nursing is examined, grounded in the American Nurses Association Code of Ethics and the International Council of Nurses Code of Ethics. Social justice, human rights, nurse migration, and approaches to nursing education are discussed within the framework of nursing's social responsibility. Strategies for addressing nursing workforce issues and education within a framework of social responsibility are explored.