Spirituality moderates the relationship between cancer caregiver burden and depression

OBJECTIVES

Cancer has become a chronic disease that requires a considerable amount of informal caregiving, often quite burdensome to family caregivers. However, the influence of spirituality on the caregivers' burden and mental health outcomes has been understudied. This study was to examine how caregiver burden, spirituality, and depression change during cancer treatment and investigate the moderating role of spirituality in the relationship between caregiver burden and depression for a sample of caregivers of persons with cancer.

METHODS

This secondary analysis used a longitudinal design employing 3 waves of data collection (at baseline, 3 months, and 6 months). Family caregivers completed the Caregiver Reaction Assessment, Spiritual Perspective Scale, and the PROMIS® depression measure. Linear mixed model analyses were used, controlling for pertinent covariates.

RESULTS

Spirituality, total caregiver burden, and depression remained stable over 6 months. More than 30% of the caregivers had mild to severe depressive symptoms at 3 time points. There was evidence of overall burden influencing depression. Of note was a protective effect of caregivers' spirituality on the relationship between depression and caregiver burden over time (b = -1.35, p = .015). The lower the spirituality, the stronger the relationship between depression and burden, especially regarding subscales of schedule burden, financial burden, and lack of family support.

SIGNIFICANCE OF RESULTS

Spirituality was a significant resource for coping with caregiving challenges. This study suggests that comprehensive screening and spiritual care for cancer caregivers may improve their cancer caregiving experience and possibly influence the care recipients' health.

Childhood Factors Associated With Unnatural Death Through Midadulthood

Importance

Life expectancy is decreasing in the US. Without national efforts to address factors that support policies and programs directed at children living in areas of concentrated poverty, life expectancy will likely continue to decline while costs and suffering associated with unnatural deaths will increase.

Objective

To identify which childhood factors are associated with death from unnatural causes through midadulthood.

Design, Setting, and Participants

For this cohort study, longitudinal data on childhood characteristics came from a group-randomized intervention trial implemented in Baltimore City Public Schools, Baltimore, Maryland (baseline 1985-1986; all students entering first grade were selected to participate at age 6 years). Participants were followed up to midadulthood with a National Death Index search through December 31, 2020. Data analysis was performed from February to May 2023.

Exposures

Exposures included individual factors (ie, sociodemographic characteristics, teacher-reported aggressive behavior, self-reported depression, anxiety, early alcohol and cannabis use, and assaultive violence exposure), family and peer factors (ie, household structure and education level, deviant peer affiliation, and parental monitoring), and neighborhood factors (ie, rates of neighborhood assault and public assistance).

Main Outcomes and Measures

The main outcome was unnatural death, defined as death due to unintentional injury, suicide, and homicide. A National Death Index search ascertained participants who died by age 41 to 42 years and cause of death. Multivariable Cox proportional hazards models were used to identify whether the exposures were independently associated with future mortality by unnatural causes.

Results

The initial trial included 2311 children, and longitudinal data were available for 2180 participants (median [IQR] age in first grade, 6.3 [6.0-6.5] years; 1090 female [50.0%]; 1461 Black [67.0%]; 1168 received free or reduced lunch in first grade [53.6%]). A total of 111 male participants (10.2%) and 29 female participants (2.7%) died; among those who died, 96 male participants (86.5%) and 14 female participants (48.3%) died of unnatural causes. Two factors remained significantly associated with mortality from unnatural causes: female sex was associated with reduced risk (hazard ratio, 0.13; 95% CI, 0.08-0.22), and neighborhood public assistance was associated with increased risk (hazard ratio, 1.89; 95% CI, 1.09-3.30).

Conclusions and Relevance

In this urban population-based cohort study, no modifiable risk factors of mortality at the level of the individual (eg, depression or anxiety and substance use) or the family (eg, household education level) were identified. However, the degree of neighborhood poverty in early childhood was significantly associated with death by unnatural causes in early adulthood, suggesting that economic policies are needed to advance health equity in relation to premature mortality.

Delivery Outcomes Among Pregnant Women With Comorbid Psychiatric and Substance Use Disorders Receiving Comprehensive Treatment

BACKGROUND: Pregnant women with substance use disorders (SUDs) are at risk for adverse delivery outcomes, and some of these women have psychiatric comorbidities that increase this risk. AIMS: Although comprehensive care models offering prenatal care services and substance abuse treatment have been found to positively affect delivery outcomes for pregnant women with SUDs, there is a dearth of research to support such models for women who have psychiatric comorbidities. METHODS: A secondary data analysis was conducted to understand the relationship between pretreatment psychiatric comorbidity and delivery outcomes for pregnant clients with SUDs receiving comprehensive treatment. We analyzed two groups of pregnant women with SUDs and hypothesized that women with psychiatric comorbidities would have worse neonatal and maternal outcomes compared with those who did not have any pretreatment psychiatric comorbidity. Regression models were used to examine changes in delivery outcome criteria (birthweight, neonatal abstinence syndrome, maternal urine toxicology screens at delivery, and hospital length of stay) in relation to psychiatric comorbidity among a sample of 74 mother-baby dyads receiving comprehensive care treatment. RESULTS: Results did not support our hypothesis as delivery outcomes were statistically similar for both groups. CONCLUSION: Findings suggest comprehensive care can reduce the risk of negative delivery outcomes among women with SUDs who have psychiatric comorbidities. Treatment and research implications are provided.

Preschoolers BMI: Associations with Patterns of Caregivers' Feeding Practices Using Structural Equation Models

Background: Childhood obesity is a major health concern. Caregivers' feeding practices are modifiable targets of obesity prevention. The study tested two hypotheses: (1) autonomy-promoting feeding practices are associated with lower BMI; and (2) diet mediates the association. We also explored examined whether feeding practices and BMI z-score (BMIz) associations are moderated by child sex, caregiver race, education, family poverty level, and food insecurity. Methods: Cross-sectional study of 437 preschoolers (44.4% girls, 38.2% Black/Other, mean age 48.1 months) and caregivers (90.2% female) from 50 child care centers. Feeding Practices were measured by Comprehensive Feeding Practices Questionnaire, child-size perception by preschooler silhouettes, temperament by the Behavior Rating Inventory of Executive Function, child diet by Young Children Food and Drink Questionnaire, and BMIz by measured weight and height. Latent profile analysis delineated feeding practice patterns. Structure equation modeling assessed the patterns in relationship to BMIz. Mediation and multiple-group analyses were used to assess mechanisms of feeding practice patterns and BMIz association. Results: From the three feeding practice patterns, Controlling, Balancing, and Regulating, Regulating was associated with lower child BMIz (b = -0.09) compared to Controlling. Higher difficult temperament (b = 0.09), higher caregiver BMIz (b = 0.26), and caregiver desire for thinner (b = 0.23) were associated with BMIz (p < 0.05). Evaluations of moderators and mediators were not significant. Conclusions: Comprehensive feeding practices support family factors related to child BMIz. Longitudinal research is needed to examine temporal associations between feeding practices and BMIz, with attention to autonomy-supporting practices, promotion of young children's self-regulation, and caregivers' perceptions of child temperament and size. Trial Registration: NCT03111264.

Gender Differences in the Interrelations Among Social Support, Stressful Life Events, and Smoking Cessation in People With Severe Mental Illnesses

BACKGROUND

Social support and stressful life events (SLEs) have been found to be influential factors for smoking cessation in the general population, but little is known about these factors among smokers with severe mental illnesses (SMIs) and whether their associations with smoking cessation differ by gender.

AIMS

To examine the association between social support and smoking cessation as mediated by SLEs in people with SMI and to examine whether the interrelations among social support, SLEs, and smoking cessation differ by gender.

METHODS

A population sample of 4,610 American lifetime adult smokers with schizophrenia, bipolar disorder, or major depressive disorder were identified in a limited public use data set of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. Four mediation and moderated mediation models were used to examine gender differences in the interrelations among social support (total and three subscales of the Interpersonal Support Evaluation List-12), SLEs (summative score of positive responses to 16 types experienced in past year and related to health, job, death, or legal situations), and smoking status in prior year.

RESULTS

Total, appraisal, and tangible support among females exerted indirect effects on smoking cessation via decreasing SLE scores. Among males, only belonging support exerted an indirect effect on smoking cessation via an increased SLE score.

CONCLUSIONS

Findings suggest that interventions focusing on improving social support should be a priority for those working with smokers with SMI.

Workplace Exposures and Prescription Drug Misuse Among Nurses

OBJECTIVE

This study examined the association between workplace exposure and prescription drug misuse in nurses.

BACKGROUND

Studies have found RNs and other health providers have higher rates of prescription misuse than the general population and have suggested that workplace exposures along with excessive job demands create circumstances fostering misuse.

METHODS

Survey data from 1170 RNs on workplace exposures (availability, frequency of administration, knowledge of substances, and workplace controls) were described by workplace, position, and specialty. Exposures were then related to prescription drug misuse using logistic regression.

RESULTS

Each workplace exposure was associated with past year prescription drug misuse. An index combining all exposures was significantly related to misuse ( P = 0.001), and odds of misuse increased by 38% for each point increase in the exposure index.

CONCLUSIONS

Consideration of the health and well-being of nurses at higher odds of exposure to prescription drugs with misuse potential is warranted. Workplace support to help nurses maintain and restore their health should be a priority.

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia

PURPOSE

Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms.

DESIGN

This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018.

METHODS

Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid.

RESULTS

There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26).

CONCLUSION

Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use.

CLINICAL RELEVANCE

Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

The role of mood disorders in the progression of and recovery from alcohol and drug use problems: A latent transition analysis

INTRODUCTION

Longitudinal research assessing whether mood disorders predict substance use behaviors is limited. We extend our prior work evaluating transition patterns with alcohol use to assess patterns with alcohol and drug use problems.

METHOD

Using National Epidemiologic Survey on Alcohol and Related Conditions prospective data, waves 1 and 2, we completed latent class analyses to empirically define classes of alcohol and drug problems from DSM disorder criteria. Latent transition analyses were used to assess associations of lifetime mood disorders at baseline with transitions across classes of alcohol and drug problems during follow-up.

RESULTS

A three-class model of alcohol and drug problems was identified (No problems, Alcohol Problems Only, and Alcohol and Drug Problems) for males and females. Females with mood disorders were over two times more likely to transition from No Problems, and Alcohol Problems Only at baseline to having both Alcohol and Drug Problems at follow-up relative to those without mood disorders (aOR=2.30, 95 % CI=1.31-4.05, p = 0.004, and aOR=2.64, CI=1.24-5.62, p = 0.011, respectively). Furthermore, females with mood disorders were significantly less likely to recover from baseline Alcohol and Drug Problems to Alcohol Problems Only at follow-up (aOR=0.35, CI=0.12-0.98, p = 0.047) relative to those without mood disorders. There were no significant findings for males.

DISCUSSION

Our study provides evidence that mood disorders impact transitions through classes of alcohol and drug problems among females. The findings emphasize the need for ongoing evaluation of substance use among those with mood conditions, and recognition and treatment of mood disorders among those recovering from substance use problems.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia

OBJECTIVES

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.

DESIGN

A mixed-methods study was performed.

SETTING AND PARTICIPANTS

During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.

METHODS

Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.

RESULTS

Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Impact of Early, Weekly Drinking on Latent Classes of Alcohol Involvement Progression and Recovery: Evidence from the NESARC Waves 1 and 2

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Weekly drinking before age 18 seems to impact alcohol progression over time.

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For females, extreme transitions from no problems to severe problems were impacted.

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For males, transitions from moderate to severe alcohol problems were impacted.

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Early, weekly drinking also predicted increased recovery for males.

Introduction

Early drinkers have been found to have higher risk of developing alcohol use disorder; however, the association of early drinking with progression to problematic alcohol involvement that does not meet disorder criteria (i.e., subclinical problems) or to severe stages of alcohol involvement, sex-specific associations, and relationship of early drinking with alcohol recovery have rarely been investigated.

Methods

Using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we applied latent transition analyses to investigate the impact of weekly drinking before age 18 on alcohol progression and recovery operationalized as three classes of alcohol involvement using abuse and dependence indicators. We analyzed data separately for male (n = 12,276) and female (n = 14,750) drinkers and applied propensity score methods to address confounding.

Results

We observed significant associations between early, weekly drinking and alcohol involvement class membership at Wave 1 for both males and females. For males, early, weekly drinking was also associated with greater odds of transitioning from moderate to severe alcohol problems (aOR = 3.19, 95% CI = 1.72, 5.35). For females, early, weekly drinking predicted the transition from no to severe problems (aOR = 2.98, 95% CI = 1.11–8.00). Contrary to our hypothesis, early, weekly drinking was associated with greater likelihood of transition from severe to no problems for males (aOR = 3.23, 95% CI = 1.26, 8.26).

Discussion

Frequent, early drinking seems to be an important indicator of drinking progression with differential associations by sex. This information is useful to identify those at greater risk of progressing to severe drinking problems to intervene appropriately.

Patterns of caregivers' feeding practices and associated characteristics among preschool-age children in the United States

During early childhood, caregiver feeding practices (FP) influence children's diet and eating habits. Inconsistent methods of operationalizing FP have resulted in limited evidence regarding simultaneous FP patterns. This study examined the heterogeneity in FP among caregivers of preschoolers, along with the child, caregiver, and family characteristics associated with FP patterns. Caregivers of preschoolers (n = 437, 90% women) enrolled in 50 childcare centers across Maryland completed the Comprehensive Feeding Practices Questionnaire (CFPQ) and provided demographic information and perceptions of their child's size and temperament. Exploratory Factor Analysis of CFPQ identified 13 factors, and latent profile analysis (LPA) empirically identified three FP classes. Using multinomial structural equation models, we regressed FP classes on child sex, race, age, poverty level, food insecurity education, caregiver perception of child size and temperament. The most common FP pattern (69%) reflected high coercive and control with low autonomy and structural practices (Controlling Class). A second pattern (16%) had high coercive control with moderate structural and autonomy practices (Regulating Class). The third pattern (15%) reflected moderate levels of all practices (Balancing Class). Caregivers who desired their child to be heavier (aOR = 0.40, 95% CI = 0.22-0.72), were more financially secure (aOR = 0.80, 95%CI = 0.65-0.98), and were single (aOR = 0.38, 95% CI = 0.18-0.80) were less likely to be in the Balancing versus Controlling class. For each unit increase in child temperament t-score [higher = difficult], caregivers were more likely to be in the Balancing (aOR = 1.04, 95% CI = 1.01-1.07) or Regulating class (aOR = 1.04, 95% CI = 1.01-1.08) compared to the Controlling class. In this statewide sample, many caregivers endorsed controlling behaviors without endorsing empowering behaviors to help children become healthy eaters. Future studies should examine how caregiver feeding practices evolve and relate to children's eating habits, growth, and development over time.

Early Life Stress and Risks for Opioid Misuse: Review of Data Supporting Neurobiological Underpinnings

A robust body of research has shown that traumatic experiences occurring during critical developmental periods of childhood when neuronal plasticity is high increase risks for a spectrum of physical and mental health problems in adulthood, including substance use disorders. However, until recently, relatively few studies had specifically examined the relationships between early life stress (ELS) and opioid use disorder (OUD). Associations with opioid use initiation, injection drug use, overdose, and poor treatment outcome have now been demonstrated. In rodents, ELS has also been shown to increase the euphoric and decrease antinociceptive effects of opioids, but little is known about these processes in humans or about the neurobiological mechanisms that may underlie these relationships. This review aims to establish a theoretical model that highlights the mechanisms by which ELS may alter opioid sensitivity, thereby contributing to future risks for OUD. Alterations induced by ELS in mesocorticolimbic brain circuits, and endogenous opioid and dopamine neurotransmitter systems are described. The limited but provocative evidence linking these alterations with opioid sensitivity and risks for OUD is presented. Overall, the findings suggest that better understanding of these mechanisms holds promise for reducing vulnerability, improving prevention strategies, and prescribing guidelines for high-risk individuals.

Caregiver burden and related factors during active cancer treatment: A latent growth curve analysis

PURPOSE

Caregiver burden is frequently studied cross-sectionally, but longitudinal studies on family caregiver burden during active cancer treatment are lacking. The goals of this study were to characterize trajectories of caregivers' burden during a 6-month active treatment period, and to examine which predictors are associated with their burden.

METHOD

This study was a secondary analysis of data from a prospective study. A sample of 112 family caregivers of patients receiving cancer treatment were assessed at three time points (the initiation of new treatment regimen, 3-, and 6-month follow-up). Caregivers completed measures: Caregiver Reaction Assessment and Mutuality Scale of the Family Care Inventory. Data were analyzed using latent growth curve modeling.

RESULTS

The two highest burdens were subdomains related to disrupted schedule and financial problems. Models showed a decline in schedule burden over time, yet total burden and other subscales (financial problems, health problems, and lack of family support and self-esteem) remained relatively stable. In multivariate analysis, mutuality, the relationship quality between patients and caregivers was inversely related to burden at baseline. Being a spouse, a sole caregiver and lower income were related to higher burden over time.

CONCLUSIONS

Our findings confirmed significant determinants of caregiver burden over the course of active treatment. It is important for health care providers to be attentive to vulnerable caregivers who are at higher risk of elevated burden over time. Considering the multidimensional nature of caregiver burden, early assessment and tailored support programs may be effective by focusing on patient-caregiver relationships, caregiving roles, and income.

Stressful life events and transitions in problematic alcohol use involvement among US adults

OBJECTIVE

We investigated the impact of stressful life events (SLEs) for males and females on transitions in problematic alcohol involvement, both progression and recovery, over a 3-year interval.

METHOD

Participants of both Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were stratified by sex (14,233 males and 19,550 females). Latent transition analysis estimated the impact of experiencing ≥3 SLE in the year preceding the Wave 1 interview on the probability of transitioning between three empirically-derived stages of alcohol involvement (patterns of alcohol use disorder [AUD] symptoms), across waves. Propensity score methods adjusted for confounding.

RESULTS

For males, three or more SLEs were associated with progression from the moderate to the severe problem stage (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17, 4.26). Among those in the severe problem stage, SLEs negatively impacted recovery regardless of sex. Employment/Financial SLEs were associated with a higher odds of transition from the moderate to the no problem stage (OR = 1.60, 95% CI = 1.03, 2.46) and lower odds of transitions from the severe to the moderate problem stage (OR = 0.40, 95% CI = 0.16, 0.99) among males, and from the severe to the no problem stage (OR = 0.26, 95% CI = 0.07, 0.88) among females.

CONCLUSION

Stressful life events appear to affect transitions in alcohol involvement over time among those who already have alcohol problems, rather than impacting a transition among those without AUD problems.

Differential Nonenrollment of Taiwanese Children in School-Based Substance Use Prevention Studies: A Multilevel Analysis

OBJECTIVE

The present study investigated the extent to which individual and school characteristics may differentially affect parental consent and child assent in the enrollment of a school-based substance use prevention study in Taiwan.

METHOD

This study linked field notes on response and consent status during enrollment of the school-based prevention study with administrative survey data reported by the targeted students when they were in fourth grade (age 10-11) (N = 2,560; 53% male, 97.8% matched). The outcome variables, defined by the combined status of parental consent/child assent, were nonresponse and negative, discordant, and positive consent. Individual characteristics included family (parental education, employment) and child (psychological/behavioral, substance use) factors. Aggregate school-level substance use and percentage of aboriginal students and nonnative parents served as school-level factors. Multilevel multinomial regression analyses were performed.

RESULTS

Successful consent was obtained from only 820 students (32%). Male gender and feeling neglected by families were associated with failing to respond (adjusted odds ratio = 1.78 and 1.71, respectively). Higher parental educational attainment reduced the odds of negative consent by 30%, whereas having unemployed parents increased the odds of discordant consent by 326%. Children attending schools with a higher percentage of indigenous students were two times more likely to have nonresponse, negative consent, and discordant consent.

CONCLUSIONS

Nonresponse to the consent request or negative consent appeared to be associated with disadvantaged background and unfavorable parent-child interaction. This suggests complex pathways underlying ascertainment and a need to modify the consent practices in school-based prevention studies involving minors, especially in schools with higher ethnic minority composition.

Adverse childhood experiences (ACEs) and transitions in stages of alcohol involvement among US adults: Progression and regression

BACKGROUND

Adverse childhood experiences (ACEs) are associated with a number of medical comorbidities. However, there is a paucity of data on the role ACEs play in transitions in stages of alcohol involvement.

OBJECTIVE

To examine the association between ACEs and transitions in alcohol problems progression and regression between No Problems, Moderate Problems and Severe Problems stages.

PARTICIPANTS AND SETTING

Data from 14,363 male and 19,774 female participants in Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

METHODS

We used latent transition analysis (LTA) with propensity score adjustment to estimate the odds of transitioning across stages of alcohol involvement, between waves, based on the number of types of ACEs experienced. We hypothesized that ACEs would be associated with increased risk of progression and decreased risk of regression.

RESULTS

ACEs were associated with progression to higher alcohol involvement stages, with greatest likelihood of progression from No Problems to Severe Problems for those reporting ≥3 ACEs (males: aOR = 4.78 [CI (1.84-12.44)]; females: aOR = 3.81 [CI (1.69-8.57)]). ACEs were also associated with decreased odds of regression to less problematic alcohol involvement stages, with some distinctive patterns of associations in males and in females.

CONCLUSIONS

This study suggests that ACEs impact transitions in alcohol involvement in both males and females, affecting both progression and regression. The association is magnified for those with multiple types of ACE exposures. These results highlight the need for prevention, early identification and intervention to mitigate the risks associated with childhood maltreatment.

Spirituality among family caregivers of cancer patients: The Spiritual Perspective Scale

Spirituality is a critical resource for family caregivers of patients with cancer. However, studies on spirituality are hampered because measures of spirituality lack consistency and have not been validated in cancer caregivers. This study examined the validity of the Spiritual Perspective Scale (SPS) among cancer caregivers and explored whether measurement bias may influence differences in spirituality across caregiver and patient characteristics. In this secondary analysis, 124 caregivers of cancer patients were used to evaluate the validity of the 10-item SPS. A multiple indicators multiple causes model was applied to explore differences in the association between a latent spirituality factor and characteristics of caregivers and patients. Overall reliability of the SPS was adequate (Cronbach's α = .95). The SPS scores were predictive of higher meaning and purpose (r = .32, p = .004) and lower depression (r = -.22, p = .046) at 3-month follow-up. Construct validity of the SPS with a single-factor structure was supported in cancer caregivers. Adjusting for a direct effect of race did not alter the pattern of results, and caregivers who were older, female, ethnic minorities, less-educated, affiliated with a religion, and who provided care to another individual in addition to the patient had greater levels of spirituality. This study provides evidence for psychometric validation of the SPS in cancer caregivers. Understanding differences in caregivers' spirituality by using the SPS with psychometrically acceptable properties and minimal measurement bias deserves more attention to optimize spirituality assessment and support in cancer caregiving.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women

BACKGROUND

Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor.

METHODS

A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes.

RESULTS

The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]).

CONCLUSIONS

Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Understanding the Impact of Bullying in a Unionized U.S. Public Sector Workforce

Background: Workplace Bullying (WPB) can have a tremendous, negative impact on the victims and the organization as a whole. The purpose of this study was to examine individual and organizational impact associated with exposure to bullying in a large U.S. unionized public sector workforce. Methods: A cross-sectional Web-based survey was conducted among 16,492 U.S. state government workers. Survey domains included demographics, negative acts (NAs) and bullying, supportiveness of the organizational climate, and individual and organizational impacts of bullying. Multinomial logistic regression was used to assess the impact among respondents who reported exposure to bullying. Findings: A total of 72% participants responded to the survey (n = 11,874), with 43.7% (n = 5,181) reporting exposure to NAs and bullying. A total of 40% (n = 4,711) participants who experienced WPB reported individual impact(s) while 42% (n = 4,969) reported organization impact(s). Regular NA was associated with high individual impact (negatively impacted them personally; odds ratio [OR] = 5.03) when controlling for other covariates including: female gender (OR =1.89) and job tenure of 6 to 10 years (OR = 1.95); working in a supportive organizational climate and membership in a supportive bargaining unit were protective of high impact (OR = 0.04 and OR = 0.59, respectively). High organizational impact (transferring to another position) was associated with regular NA and bullying (OR = 16.26), female gender (OR = 1.55), providing health care and field service (OR = 1.68), and protective effect of organizational climate (OR = 0.39). We found a dose-response relationship between bullying and both individual and organizational-level impact. Conclusion/Application to Practice: Understanding the impacts of WPB should serve to motivate more workplaces and unions to implement effective interventions to ameliorate the problem by enhancing the organizational climate, as well as management and employee training on the nature of WPB and guidance on reporting.

Current tobacco use, nicotine dependence, and transitions across stages of alcohol involvement: A latent transition analysis approach

OBJECTIVES

This study aims to examine the (a) probability of transition between stages of alcohol involvement and (b) influence of tobacco use and nicotine dependence on transitions.

METHODS

Data came from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Latent transition analysis estimated the probability of transitioning between stages of alcohol involvement across waves and the impact of tobacco use and nicotine dependence at Wave 1 on transitions.

RESULTS

Males reporting current tobacco use but no dependence at Wave 1 were more likely to progress from No Problems to Moderate Problems (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI] [1.44, 2.22]) and from No Problems to Severe Problems (aOR = 2.44; 95% CI [1.25, 4.77]) than nontobacco users. Females reporting current tobacco use but no dependence were more likely to progress from No Problems to Moderate Problems (aOR = 2.00; 95% CI [1.37, 2.94]) and from No Problems to Severe Problems (aOR = 2.87; 95% CI [1.34, 6.13]). Females reporting current tobacco use and dependence were more likely than females not using tobacco to transition from Moderate to No Problems (aOR = 2.10; 95% CI [1.04, 4.22]).

CONCLUSIONS

Results suggest that tobacco use is a preceding correlate of progression in alcohol involvement among males and females. Among females, tobacco use and nicotine dependence are also related to alcohol involvement recovery.

The Effects of Marijuana Use on Transitions through Stages of Alcohol Involvement for Men and Women in the NESARC I and II

Background: With the changing context of marijuana use, it is critical to identify effects of use. We extend previous work by examining whether marijuana use influences progression and remission through alcohol involvement stages for men and women. Methods: Data come from Waves I and II of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n = 34,432). We assess the potential influence of marijuana use at Wave 1 on transitions across three latent statuses of alcohol involvement between waves. We apply propensity score weighting to account for shared risk factors. Results: Marijuana use was associated cross-sectionally and longitudinally with alcohol involvement statuses for both sexes. After propensity score adjustment, men with marijuana histories were 3.50 times as likely as men without such histories to transition from no to severe problems across waves relative to staying in the same status (p < .001). Women with marijuana histories were 1.74 times as likely as women without such histories to transition from no problems at Wave 1 to moderate problems at Wave 2 (p = .030) and 0.13 times as likely as women without such histories to transition from severe problems to no problems (p = .006). Conclusions: Results suggest that marijuana use impacts progression to more serious stages of alcohol involvement for both men and women, as well as hinders remission among women. Findings point to the importance of screening those with marijuana histories for alcohol problems, as well as the need to understand the mechanism of why marijuana use may increase the risk of alcohol problems.

Women's Prenatal and Labor Experiences in a Hospital With an Early-Labor Lounge

OBJECTIVE

To evaluate the information that women with low-risk pregnancies received during the prenatal period about latent labor and the early-labor lounge (ELL) and their subsequent use of the ELL.

DESIGN

Cross-sectional design with survey.

SETTING/LOCAL PROBLEM

Community hospital in the northeastern United States with a low-risk cesarean birth rate of 33%, which exceeds the national target rate of 23.9%.

PARTICIPANTS

Low-risk, nulliparous, pregnant women with a term singleton vertex fetus at hospital admission (N = 67).

INTERVENTION/MEASUREMENTS

An electronic survey was administered before hospital discharge following birth. The survey assessed prenatal education, use of the ELL, admission characteristics, and birth satisfaction. Descriptive analysis was used.

RESULTS

Nearly half (43.9%) of the women surveyed used the ELL. ELL users received prenatal care (72.3%), knew signs of active labor (93.1%), and had a cesarean birth rate of 7.1%. Significantly greater proportions of women prenatally cared for by midwives reported knowledge of the signs of early labor (100% vs. 80%; χ² = 4.4, p = .04) and of the availability of the ELL (18.2% vs. 70.6%; χ² = 15.2, p < .001). A range of activities were offered in the ELL, and at least 75% of women indicated that all activities were helpful during latent labor. Birth satisfaction scores, measured on a scale of 0 to 40, with 40 indicating greatest satisfaction, ranged from 22 to 35 among ELL participants.

CONCLUSION

An ELL is a care innovation that hospitals can consider for providing support to women with low-risk pregnancies during the latent phase of labor. Women who used the ELL reported feeling that it provided guidance and support. An ELL is a woman-centered option for delayed admission.

Associations Among Intrapartum Interventions and Cesarean Birth in Low-Risk Nulliparous Women with Spontaneous Onset of Labor

INTRODUCTION

Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth.

METHODS

This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth.

RESULTS

More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21).

DISCUSSION

Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Toddler Bedtime Routines and Associations With Nighttime Sleep Duration and Maternal and Household Factors

STUDY OBJECTIVES

The aims of this study were to examine (1) relationships among implementing a bedtime routine, nighttime awakenings, and nighttime sleep duration in toddlers from low-income, minority families and (2) differences in maternal and household characteristics between mothers who did versus those who did not implement a nightly bedtime routine for their toddler.

METHODS

Data were collected from mothers of toddlers on maternal and household characteristics and toddler sleep, measured using the Children's HealthWatch Survey and the Extended Brief Infant Sleep Questionnaire (BISQ). A path analysis model was tested to investigate whether nighttime awakenings mediated the relation between implementing a bedtime routine and toddlers' nighttime sleep duration. Chi-square tests were conducted to examine differences in maternal and household characteristics (ie, maternal depressive symptoms, food, housing and energy insecurity) between mothers who did versus those who did not implement nightly bedtime routines over the past 2 weeks.

RESULTS

Implementing a bedtime routine was associated with longer toddler sleep duration through a decrease in nighttime awakenings (β = 5.04, 95% confidence interval = 0.61 to 11.35). More consistent sleep routine implementation was associated with fewer nighttime awakenings and longer sleep duration. Maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of implementing a nightly bedtime routine.

CONCLUSIONS

Maternal depressive symptoms, food insecurity, and household insecurity (factors associated with low socioeconomic status) may be associated with a negative sleep environment and poor toddler sleep quality, potentially because of decreased implementation of bedtime routines.

COMMENTARY

A commentary on this article appears in this issue on page 821.

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women

BACKGROUND

Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor.

METHODS

This was a cross-sectional, observational study of 21 858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode.

RESULTS

In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3 cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5 cm (2.49 [2.15-2.89]) compared to 6-10 cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3 cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5 cm (2.27 [1.86-2.77]) compared to 6-10 cm.

CONCLUSIONS

To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Comparative psychometric review of the Negative Acts Questionnaire-Revised in a unionized U.S. public sector workforce

BACKGROUND

Workplace violence is a global problem that includes actions collectively defined as bullying as perpetrated by a work colleague.

PURPOSE

Two distinct studies were conducted to assess the feasibility of using an abridged 6-item scale within the 21- item Negative Acts Questionnaire-Revised (NAQ-R) designed to assess workplace bullying.

METHODS

The pilot study was a psychometric review of the 21-item NAQ-R, and the main study was conducted to determine the reliability and the validity of using a 6-item version. Cronbach's alpha assessed the internal consistency of the two versions of the NAQ-R. Validity was assessed using logistic regression with theoretically related constructs with a pilot study (n = 420) using the 21-item scale, followed by the main study (n = 11,874) using the 6-item version.

RESULTS

Both the pilot study (21-item)and the main study (6-item) versions of the NAQ-R demonstrated high internal consistency (Cronbach's alpha 0.93-0.86, respectively). Similar to the 21-item, the 6-item version had a significant impact on the intent to remain on the job, being personally affected, and supported the protective role of the organizational climate against exposure to negative acts.

CONCLUSION

This study supports using the 6-item NAQ-R, which can reduce respondent burden and streamline data gathering and analysis.

Transitions through stages of alcohol involvement: The potential role of mood disorders

INTRODUCTION

Although prior clinical and population-based studies have demonstrated comorbidity between mood and alcohol use disorders (AUD), there is a paucity of research assessing whether mood disorders predict transition across stages of alcohol involvement.

METHOD

Hypothesizing that mood disorders predict transition across sex-specific alcohol involvement stages, we used prospective data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey of US adults, which included male (n = 14,564) and female (n = 20,089) participants surveyed in 2001-2 and re-interviewed in 2004-5. Latent class (LCA) and latent transition analyses (LTA) were used to assess patterns of alcohol involvement in the US and the association of lifetime mood disorders at baseline with transition across stages of alcohol involvement during follow-up.

RESULTS

A three-class model of AUD criteria was identified (No problems, Moderate problems and Severe problems) for both sexes. Positive cross-sectional associations between mood disorder and problem classes of alcohol involvement were found among both sexes, as were positive longitudinal associations. Propensity score adjustment mitigated the associations of baseline mood disorder with progressive transition for both sexes. However, among females, baseline mood disorder was consistently associated with reduction in remission from Severe to Moderate alcohol problems (aOR = 0.30, CI = 0.09-0.99, p = .048) over time.

DISCUSSION

Our study provides evidence that mood disorders impact transition through stages of alcohol involvement and are most strongly associated with hindering remission among females. Findings advance our understanding of these comorbid relationships and have clinical implications for ongoing assessment of drinking patterns among individuals with mood disorders.

CNA Training Requirements and Resident Care Outcomes in Nursing Homes

Purpose of the Study

To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasing complexity of care. Yet little is known about the impact of the type and amount of training CNAs are required to have on resident outcomes.

Design and Methods

Compiled data on 2010 state regulatory requirements for CNA training (clinical, total initial training, in-service, ratio of clinical to didactic hours) were linked to 2010 resident outcomes data from 15,508 NHs. Outcomes included the following NH Compare Quality Indicators (QIs) (Minimum Data Set 3.0): pain, antipsychotic use, falls with injury, depression, weight loss and pressure ulcers. Facility-level QIs were regressed on training indicators using generalized linear models with the Huber-White correction, to account for clustering of NHs within states. Models were stratified by facility size and adjusted for case-mix, ownership status, percentage of Medicaid-certified beds and urban-rural status.

Results

A higher ratio of clinical to didactic hours was related to better resident outcomes. NHs in states requiring clinical training hours above federal minimums (i.e., >16hr) had significantly lower odds of adverse outcomes, particularly pain falls with injury, and depression. Total and in-service training hours also were related to outcomes.

Implications

Additional training providing clinical experiences may aid in identifying residents at risk. This study provides empirical evidence supporting the importance of increased requirements for CNA training to improve quality of care.

Nurse Practitioner Independent Practice Authority and Mental Health Service Delivery in U.S. Community Health Centers

OBJECTIVE

Little is known about how nurse practitioner independent practice authority (NP-IPA) influences patient care. This study examined the effect of NP-IPA on patterns of mental health-related visits provided by NPs in U.S. community health centers (CHCs).

METHODS

State NP regulatory information was linked to National Ambulatory Medical Care Survey data on NP- and physician-provided visits (N=61,457) in CHCs from 2006 through 2011. The proportion of NP-provided versus physician-provided mental health-related visits in states with NP-IPA was compared with the proportion in states without NP-IPA. The adjusted odds of mental health-related visits in CHCs provided by NPs in states with and without NP-IPA were compared by using multiple logistic regression models while accounting for the complex survey design.

RESULTS

Between 2006 and 2011, the odds of NP- versus physician-provided mental health-related visits in CHCs were more than two times greater in states with NP-IPA than in states with no NP-IPA (adjusted odds ratio [OR]= 2.43, 95% confidence interval [CI]=1.12-4.60). In contrast, no significant difference between states with and without NP-IPA was noted in non-mental health-related CHC visits provided by NPs. Among all mental health-related visits, the odds of visits in which psychotropic medications were prescribed by an NP were more than three times higher in states with NP-IPA than in those without NP-IPA (adjusted OR=3.14, CI=1.50-6.54).

CONCLUSIONS

Compared with physicians, NPs provided proportionally more CHC mental health-related visits in states with NP-IPA than in states without NP-IPA.

Language Barrier as a Risk Factor for Injuries From Patient Violence Among Direct Care Workers in Home Settings: Findings From a U.S. National Sample

This study explored potential risk factors for injuries from patient violence among direct care workers in U.S. homes (DCWHs). A national probability sample of 3,377 DCWHs including home health and personal care aides was analyzed using complex sample analysis and generalized estimating equation. Injury from violence was defined as a workrelated injury sustained by aggression, violence, or abuse that was reported to the agency, required medical attention or resulted in absenteeism from work. An association between suffering an injury from patient violence and having a language barrier with patients was noted (OR = 4.44; 95% CI = 1.57, 12.56; p = .005). Findings illuminate the importance of homecare providers to match language between DCWHs and patients to reduce patient violence and improve quality of care in the home setting.

Exploring the Factor Structure of the Job Demands-Resources Measure With Patient Violence on Direct Care Workers in the Home Setting

BACKGROUND AND PURPOSE

Workplace violence research in health care settings using the Job Demands-Resources (JD-R) framework is hindered by the lack of comprehensive examination of the factor structure of the JD-R measure when it includes patient violence. Is patient violence a component of job demands or its own factor as an occupational outcome?

METHOD

Exploratory factor analysis and confirmatory factor analysis were conducted using a sample of direct care workers in the home setting (n = 961).

RESULTS

The overall 2-construct JD-R structure persisted. Patient violence was not identified as a separate factor from job demands; rather, two demand factors emerged: violence/emotional and workload/physical demands.

CONCLUSIONS

Although the three-factor model fits the data, the two-factor model with patient violence being a component of job demands is a parsimonious and effective measurement framework.

Latent classes of caregiver relationships with patients: Workplace violence implications

The bonds and relationships that direct care workers in the home setting (DCWHs) develop with their elderly or disabled home care patients may put them at risk for patient violence. This study used a data-driven approach, latent class analysis, to identify distinct underlying patterns of DCWH-patient relationships and then assessed how DCWH-patient class membership was associated with patient violence. This study analyzed survey data obtained from 964 DCWHs working in two not-for-profit home care agencies. Four classes of DCWH-patient relationships emerged: Non-familial (40% of the sample), Overly Concerned (14%); Boundary-keeping (22%), and Overly Involved (24%). DCWHs in the Overly Involved class were more likely to experience physical violence from their patients relative to those in the Non-familial class (probability = 0.11 vs. 0.04, p = 0.01). Building a positive relationship with boundaries between caregivers and patients may have a potential to reduce patient violence toward the caregivers and ultimately improve the quality of care.

Variation Across U.S. Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing

PURPOSE

Though more people in the United States currently reside in assisted living facilities (ALFs) than nursing homes, little is known about ALF admission policies, resident care needs, and staffing characteristics. We therefore conducted this study using a nationwide sample of ALFs to examine these factors, along with comparison of ALFs by size.

DESIGN

Cross-sectional secondary data analysis using data from the 2010 National Survey of Residential Care Facilities.

METHODS

Measures included nine admission policy items, seven items on the proportion of residents with selected conditions or care needs, and six items on staffing characteristics (e.g., access to licensed nurse, aide training). Facilities (n = 2,301) were divided into three categories by size: small, 4 to 10 beds; medium, 11 to 25 beds; and large, 26 or more beds. Analyses took complex sampling design effects into account to project national U.S. estimates.

FINDINGS

More than half of ALFs admitted residents with considerable healthcare needs and served populations that required nursing care, such as for transfers, medications, and eating or dressing. Staffing was largely composed of patient care aides, and fewer than half of ALFs had licensed care provider (registered nurse, licensed practical nurse) hours. Smaller facilities tended to have more inclusive admission policies and residents with more complex care needs (more mobility, eating and medication assistance required, short-term memory issues, p < .01) and less access to licensed nurses than larger ALFs (p < .01).

CONCLUSIONS

This study suggests ALFs are caring for and admitting residents with considerable care needs, indicating potential overlap with nursing home populations. Despite this finding, ALF regulations lag far behind those in effect for nursing homes. In addition, measurement of care outcomes is critically needed to ensure appropriate ALF care quality.

CLINICAL RELEVANCE

As more people choose ALFs, outcome measures for ALFs, which are now unavailable, should be developed to allow for oversight and monitoring of care quality.

Gambling Disorder and Minority Populations: Prevalence and Risk Factors

PURPOSE OF REVIEW

Previous studies demonstrate disparities in health and health services including gambling disorders (GD) among ethnic and racial minority groups. In this review, we summarize studies examining the prevalence of GD across different ethnic and racial minorities.

RECENT FINDINGS

We describe the sociodemographic subgroup variations at heightened risk for GD and factors associated with GD in racial and ethnic minority groups including gambling availability, comorbid substance use, psychiatric conditions, stress, acculturation, and differences in cultural values and cognitions. We found that research of GD among minority groups is scant, and the prevalence of GD among these groups is at a magnitude of concern.

SUMMARY

Racial and ethnic minority status in it of itself is not a risk factor for GD but may be a proxy for underlying potential risk factors. The need for prevention and treatment programs for different cultural group remains unmet.

Latent classes of childhood trauma exposure predict the development of behavioral health outcomes in adolescence and young adulthood

BACKGROUND

To develop latent classes of exposure to traumatic experiences before the age of 13 years in an urban community sample and to use these latent classes to predict the development of negative behavioral outcomes in adolescence and young adulthood.

METHOD

A total of 1815 participants in an epidemiologically based, randomized field trial as children completed comprehensive psychiatric assessments as young adults. Reported experiences of nine traumatic experiences before age 13 years were used in a latent class analysis to create latent profiles of traumatic experiences. Latent classes were used to predict psychiatric outcomes at age ⩾13 years, criminal convictions, physical health problems and traumatic experiences reported in young adulthood.

RESULTS

Three latent classes of childhood traumatic experiences were supported by the data. One class (8% of sample), primarily female, was characterized by experiences of sexual assault and reported significantly higher rates of a range of psychiatric outcomes by young adulthood. Another class (8%), primarily male, was characterized by experiences of violence exposure and reported higher levels of antisocial personality disorder and post-traumatic stress. The final class (84%) reported low levels of childhood traumatic experiences. Parental psychopathology was related to membership in the sexual assault group.

CONCLUSIONS

Classes of childhood traumatic experiences predict specific psychiatric and behavioral outcomes in adolescence and young adulthood. The long-term adverse effects of childhood traumas are primarily concentrated in victims of sexual and non-sexual violence. Gender emerged as a key covariate in the classes of trauma exposure and outcomes.

Depression among Asian-American Adults in the Community: Systematic Review and Meta-Analysis

OBJECTIVES

In this systematic review, we provide an overview of the literature on depression among Asian-Americans and explore the possible variations in depression prevalence estimates by methodological and demographic factors.

METHODS

Six databases were used to identify studies reporting a prevalence estimate for depression in Asian-American adults in non-clinical settings. Meta-analysis was used to calculate pooled estimates of rates of depression by assessment type. Statistical heterogeneity was assessed for subgroup analyses by gender, age, ethnicity, and other participant characteristics.

RESULTS

A total of 58 studies met the review criteria (n = 21.731 Asian-American adults). Heterogeneity across the studies was considerably high. The prevalence of major depression assessed via standardized clinical interviews ranged between 4.5% and 11.3%. Meta-analyses revealed comparable estimated prevalence rates of depression as measured by the Center for Epidemiologic Studies Depression Scale (35.6%, 95% CI 27.6%-43.7%) and the Geriatric Depression Scale (33.1%, 95% CI 14.9%-51.3%). Estimates varied by Asian racial/ethnic group and other participant characteristics. Estimates of depression among special populations, which included maternity, caregivers, and homosexuals, were significantly higher than estimates obtained from other samples (58.8% vs 29.3%, p = .003). Estimates of depression among Korean and Filipino-Americans were similar (33.3%-34.4%); however, the estimates were twice as high as those for Chinese-Americans (15.7%; p = .012 for Korean, p = .049 for Filipino).

CONCLUSION

There appears to be wide variability in the prevalence rates of depression among Asian-Americans in the US. Practitioners and researchers who serve Asian-American adults need to be sensitive to the potential diversity of the expression of depression and treatment-seeking across Asian-American subgroups. Public health policies to increase Asian-American access to mental health care, including increased screening, are necessary. Further work is needed to determine whether strategies to reduce depression among specific Asian racial/ethnic groups is warranted.

Sources of nonmedically used prescription stimulants: differences in onset, recency and severity of misuse in a population-based study

AIM

Epidemiological data indicate that nonmedical use of prescription stimulants has increased over the past decade. However, little is known regarding the source of the misused stimulants and whether different sources correspond to differences in risk profiles and associated social and health problems.

METHOD

Data from the 2006 to 2011 National Survey on Drug Use and Health were used. A total of 4945 participants who used prescription stimulants nonmedically and also reported their source of misused stimulants were categorized by the source: friend/relative, physician and illegal. Logistic regression models compared the socio-demographic, mental health and behavioral problems, and stimulant use-related problems (onset, recency, frequency, severity) according to the source of the misused stimulants.

RESULTS

The most common sources of stimulants were friends/relatives, followed by physicians and illegal sources. Compared to participants reporting friends/relatives as the source, participants reporting an illegal source were more likely to be male, unemployed, have less than a high school education, a history of criminal behavior and an earlier age of use onset. Participants reporting a physician source were more likely to have mental health problems and mental health service use. Higher odds of past-month stimulant use, frequent use (≥ 10 days per year), drug dependence and substance service use were found in individuals reporting physician and illegal sources.

CONCLUSIONS

Identifying the source of misused stimulants may be useful in detecting distinct subgroups of nonmedical prescription stimulant users, which may inform development of tailored prevention and treatment programs and contribute to individual treatment planning.