Gay and bisexual men infected with human immunodeficiency virus (HIV) comprise a sizable, medically vulnerable population. Depression is the most commonly experienced mental health disorder affecting this group of people, lending itself to a host of risks associated with depression. As screening of depression in this population can be challenging, it is vital that clinicians have the best available tools and guidelines to detect depressive symptomology. This focused, comprehensive review of the literature examined current data describing the clinical instruments used to detect depressive symptoms in HIV-infected gay and bisexual men. The aim of this analysis was to seek out which instruments were the most widely and successfully employed for this population. An initial search using EBSCOhost and associated databases CINAHL, MEDLINE, PsycINFO, and Health and Psychosocial Instruments alongside inclusion and exclusion criteria found 1,899 articles. Results were narrowed using additional inclusion and exclusion criteria and relevancy, yielding a total of 13 articles for review. The findings of this review suggest screening of depressive symptoms in HIV-infected gay and bisexual men was most successful using the CES-D, the BSI-18, and the BDI. Health care providers should have an understanding of the importance in assessing this population for depression and have access to the best possible tools to do so.

Childhood obesity is a global health concern that puts children at risk for developing serious health complications. With increasing rates worldwide, it is important to determine how to decrease its prevalence and promote prevention in future generations. Emerging evidence indicating that pre-pregnancy weight status and/or gestational weight gain (GWG) may be linked with overweight/obesity in children. Much of this body of research focused on weight status of offspring at birth and at preschool age. The purpose of this study is to: (1) analyze the research findings regarding obesity in children 5 to 18 years and their mother’s pre-pregnancy weight status and/or GWG, and (2) make recommendations for prevention based on a review of current research. A database search of CINAHL, Medline, ERIC and PsycInfo was conducted. A total of 14 articles were identified based on their relevance to key search terms and meeting criteria. This literature review indicated support for associations between an underweight/overweight/obese pre-pregnancy weight status combined with greater than recommended total GWG and higher overweight/obesity in older children and adolescent offspring. Findings also supported the associations between pre-pregnancy weight status with high GWG during early pregnancy and increased offspring overweight/obesity. Pre-pregnancy overweight/obese weight status of mothers was the single factor consistently found to be strongly associated with risk for overweight and obesity in children 5 to 18 years of age. Results of this review support the need for further education, interventions, and policies aimed at healthy nutrition for women during and prior to pregnancy to prevent childhood obesity.

The topic of substance-abuse has received increasing attention in recent years, as the number of individuals experiencing drug abuse and addiction is on the rise. With substance-use on the rise, the number of patients admitted to the hospital with this disorder is increasing also. It is important hospital staff are aware and educated on how to provide adequate care to these patients without judgement regarding their choices or their lifestyle. This study was done to determine how prepared nursing students are to care for patients with drug abuse or addiction. Specifically, the project explores student nurses' attitudes and commitment toward substance- abusing patients. The 20 item Drug and Drug Problem Perceptions Questionnaire (DDPPQ) was used to measure attitudes and therapeutic commitment in working with drug-abusing patients, and was distributed electronically to approximately 400 nursing students. One hundred thirty-one students participated. Scores ranged from 22-102, with the smaller value representing greater overall commitment and preparedness when working with substance-abusing patients. The mean score reported overall was 58. This score indicates improvement is needed to increase students' therapeutic commitment and ability to provide quality care for patients experiencing substance- abuse. More research needs to be done and programs put into place to reach this goal.

The Rural Expansion Program for At-risk Communities to Promote Health Outcomes through the Integration of Mental health and Enabling services in an Existing Primary Care School-Based Setting (REACH ME) program was established to increase access to mental health services at two existing school-based health centers (SBHC) in rural Hancock County, TN. These SBHCs are among the most unique in the nation, holding designations as federally funded qualified health centers - proving primary care services in a geographically isolated, rural, and medically underserved area. The aim of the project is increasing the number of patients receiving mental health and enabling services for not only the children and adolescents of Hancock County, but also adults who use the clinic for primary care services. This project employs a secondary data analysis to determine if there is an increase in the use of mental health services by patients using a school-based health center for care. Variables include number of visits, screening employed, and mental health diagnosis. Data gathered by health center staff and input into Excel will be used. Data collection is ongoing and is expected to be completed in February 2024. Early results indicate an increase in mental health and enabling services from initiation of the project. There were identified facilitators and barriers that impacted the project. Significance for this project is two-fold, identified facilitators and barriers to initiating integrated mental health services in the SBHC setting and increasing early screening, identification, referral and treatment of rural populations with mental health problems.

Trauma informed care nursing education is crucial. Trauma informed care is a method of providing health care which understands the likelihood of past and present traumatic events in patients and families. The experience of past or present trauma often led to chronic diseases, substance abuse disorder, fragmented health care, fears surrounding health care, chronic stress, and other negative health consequences. The purpose of this project is to increase licensed nurses’ awareness and ability to practice trauma informed care in clinical practice, as well as promote policy initiation within the health care facilities. Method planning integrated the Knowledge to Action Cycle. A two hour, Delphi reviewed, evidenced based educational session was developed for licensed nurses in two health care facilities. After the educational session is completed, an anonymous survey will be distributed to determine the licensed nurses’ awareness of trauma informed care. A second anonymous survey will be sent four weeks later to assess changes in clinical practice based on trauma informed care education. One educational session for eleven licensed nurses working in a psychiatric facility has been completed. Two preliminary themes emerged from the first survey. The first theme was more intentional focus on integrating trauma informed care principles into practice. The second theme was an increased need for self-care. Two more educational sessions are planned for licensed nurses in an acute care hospital. Keywords: trauma informed care, nursing, education, KTA Cycle, health care, policy

Older Americans will soon outnumber children and younger adults. In 2022, there were 58 million older adults. By 2050, older adult numbers will grow to 82 million, and by 2060, 100 million. The National Institute on Aging calls for ongoing research on the impact that a historically large aging population will have on health, well-being, and quality of life. A key concern is how to meet needs while decreasing costs associated with institutional long-term care. Most of these elders reside in the community and wish to live in their homes throughout their lives, but they will experience an increased need for age-related healthcare and resources in their rural communities. There is little in the literature about these issues. A qualitative, descriptive, phenomenological study was undertaken to describe the availability of resources for aging in place through the lens of rural community service workers' lived experience and perceptions. The study was underpinned theoretically with Rural Nursing Theory and conceptually by principles of aging in place. Resulting themes included easily vs not easily accessible resources for aging in place, bridges or battles to support aging in place, and big dysfunctional puzzle of fragmented and scattered resources. By focusing on aspects of rural environments and concepts of aging in place, the study describes the contextual differences of rural aging in place, illuminates the reality of rural aging, and highlights the need for cost-effective expansion of age-related resources for rural aging in place.

Background: Health literacy is defined as one’s ability to find, comprehend, and utilize information to make health decisions (Office of Disease Prevention and Health Promotion, n.d.). Globally, nursing students are exposed to the concept of health literacy during their degree-seeking years, yet no formal health literacy education exists across nursing curricula in pre-licensure programs at the associate and bachelor levels. This lack of standardization and non-emphasis of health literacy as a formal topic within education has contributed to poor provider performance and, in turn, low health literacy rates that may lead to suboptimal patient outcomes. Significance: Studies have found that “approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes” (Berkman et al., 2011). Since the late 1990s, these poor outcomes have led to those of limited health literacy to become more likely to be admitted than those of adequate health literacy levels, which are all preventable consequences of an overlooked public health matter (Baker et al., 1998). Methods: A multi-database search on CINAHL, ERIC, and MEDLINE was conducted using key terms such as “students, nursing”, “nurs*”, “patient education” and “skill”. After a final full text review, 12 articles were deemed appropriate for inclusion in this literature review on self-efficacy of nursing students regarding health literacy and patient education. Conclusion: The studies analyzed for this review demonstrate positive benefits from a multi-modal approach to health literacy education within nursing curricula. Student perspectives revealed foundational skills regarding health literacy but limited support from faculty and curricula in further developing knowledge on the subject, relying instead on students’ independent learning through clinical experiences. Implications for Nursing: Further research may aim to examine the effectiveness of a standardized health literacy curriculum across a variety of nursing programs as well as its longitudinal effects on students’ self-efficacy and quality patient-teaching as they transition into licensed practice.

This study was designed to explore the literature on competitive food policy implementation (CFPI); examines demographic and school factors associated with CFPI; and explores the experiences of school leaders and staff in CFPI using a proposed theoretical framework to guide the research. Competitive foods are those sold in vending machines, a la carte settings, fundraisers, class parties and other venues which compete with foods offered through the national school lunch and breakfast programs. Competitive foods have traditionally been of low nutritional value and high energy density. CFPI may be effective in reducing student calorie intake and BMI. However, evaluation of competitive food policy effectiveness is difficult due to variability in policy implementation. A theoretical framework is needed to guide research on CFPI. This research was a mixed methods study including a review of the literature, quantitative secondary analysis, and a qualitative content analysis of transcripts from semi-structured interviews with school personnel to understand their experience with CFPI. First, a systematic review of the research literature on CFPI was conducted. Demographic and school factors, policy features, and school and parent/community-level factors that impact CFPI were identified. Second, the association of multiple demographic and school factors with CFPI scores was examined. CFPI scale (overall) and sub-scales (“inside” and “outside” school) were developed and validated to evaluate CFPI effectiveness in Kentucky middle and high schools (N=640, grades 5-12). The scales were based on responses to 8 questions on competitive food practices from a 2011 School Tobacco and Wellness Policy biannual survey conducted by the University Of Kentucky College Of Nursing Tobacco Policy Research Program. Student BMI tracking and presence of a written wellness policy predicted higher scores on the overall CFPI scale (BMI OR=2.06, p=0.001; Wellness OR=1.74, p=0.02), inside subscale scores (BMI OR=2.46, p<0.0001; Wellness OR=1.58, p=0.05), and outside subscale scores (BMI OR=2.27, p=0.03; Wellness OR=1.54, p=0.0005). Greater county-level adult obesity rates predicted lower overall CFPI scores (OR=0.93, p=0.02). Private school status predicted lower scores on inside CFPI subscale scores (OR=0.47, p=0.004). Third, semi-structured interviews were conducted with 23 school personnel to explore CFPI. Interviews were recorded, transcribed and content analysis was conducted. Kentucky schools were stratified into four groups based on school level (middle or high) and CFPI scores (high or low). Sixteen schools were randomly selected for each of the four groups. A total of eight schools, two from each group, agreed to participate. The interview guide was based on a proposed CFPI framework based on implementation science, educational and organizational theory research. Six key themes emerged: internal/external forces enabling CFPI; internal and external obstacles to CFPI; key organizational values; organization value of CFPI; methods that organizations use to communicate organizational values; and CFPI policies and procedures. Findings were discussed in the context of the proposed theoretical framework. Implications for policy, practice and future research are presented.

Globally, in low and middle-income countries 4 out of every 10 pregnancies is reported to be unintended. Having an unintended pregnancy increases the risk of maternal and infant morbidity and mortality, preterm birth, low birth weight, and decreases rates of breast-feeding. The United States (U.S.) consistently has some of the highest rates of preterm birth, infant and maternal mortality of all high-income countries and 45% of all pregnancies in the U.S. are reported to be unintended. The etiology of these outcomes and their relationship to pregnancy intention are complex and multifactorial, but we know this disproportionately effects women living in poverty both in the U.S. and globally. When couples have the knowledge, access, and power to decide when and whether to become pregnant they are more likely to seek preconception care, thus increasing the likelihood of planned pregnancies leading to improved maternal and child health outcomes. Primary prevention strategies to improve maternal/child health outcomes in the U.S. include sexual and reproductive health considerations such as increasing access to birth control. Globally, strategies include expanding access, as well as focusing on the empowerment of women and improving gender social norms. Focusing on community level norms and individual empowerment can lead to greater reproductive autonomy, which in turn leads to an increase in the uptake of birth control and family planning. This broader consideration of multiple levels of power or autonomy is often lacking in approaches taken in the U.S. More information is needed about the social context and determinants of pregnancy intention in our communities, particularly of women living in poverty. The purposes of this dissertation were to 1) to describe reproductive autonomy and family planning challenges in a population of marginalized Ecuadorian women; 2) develop a conceptual framework of reproductive autonomy from the global literature; 3) to validate a shortened form of an interpersonal violence scale used in a study of low-income pregnant women in Kentucky; and finally 4) to investigate the association between pregnancy intention and individual, interpersonal and community factors of impoverished women living in Kentucky. The qualitative study of women in Ecuador identified barriers and facilitators to family planning in a low-resource community. The major themes that emerged were that women’s autonomy was limited by men, shame was ‘keeping women quiet’, systems failed women, and as women aged they were able to build resilience in spite of these challenges. Many reported reproductive coercion, gender-based violence, and regret. Those who could leave unsupportive partners and found social support were more effective at planning their pregnancies. Evidence supports these themes are relatively common in the global literature, particularly of women living in poverty. The comprehensive review of these findings was used to develop a conceptual framework of reproductive autonomy. The Socio-Ecological Model was used to organize the data based on individual, interpersonal or community level determinants of pregnancy intention and reproductive autonomy. This new conceptual model, called the Power and Reproductive Autonomy (PARA) model, was used as a guide to analyze multiple levels of data in a secondary analysis of pregnant women living in poverty in Kentucky. Prior to this secondary analysis study, a measure used in the parent study needed to be validated. A short form of the Women’s Experience with Battering (WEB) scale was found to be psychometrically valid to measure of the impact of intimate partner violence for this population. Findings from the secondary analysis included high rates of unintended pregnancy (66%), and women with unintended pregnancy were more likely to report exposure to interpersonal violence, poor social support, and anxiety at the bivariate level. At the community (county) level those with an unintended pregnancy were more likely to live in counties with fewer social associations, and in rural communities. None of the access, gender equity, income inequality, or violence variables were correlated to pregnancy intention. In the final multilevel model, controlling for demographic variables, only being unmarried and answering the question in English were significant predictors of unintended pregnancy. The rate of social associations in a county was marginally significant with pregnancy intention, in that the presence of social associations appeared to decrease the likelihood of unintended pregnancy. Operationalizing the PARA framework to examine predictors of unintended pregnancy in Kentucky proved to not yield expected results; county level variables related to access, gender equity, and violence were not found to be significantly correlated. Women answering the question in Spanish had significantly higher rates of planned pregnancy, which is a new finding. Having opportunities for social engagement also seemed to be a protective factor in preventing unintended pregnancies. Limitations of cross-sectional data also make it a challenge to capture cumulative life stressors which could contribute to poor reproductive autonomy. Future studies may yield a greater understanding of the social context of pregnancy intention if more interpersonal data related specifically to reproductive autonomy are in the model, such as reproductive coercion, relationship power, communication, and contraceptive decision making. Additionally, further examination of structures or systems that provide economic opportunities in the community is a promising area of reproductive autonomy and pregnancy intention research.

Background: The Theory of Cultural Distress offers a framework for understanding the potential outcomes in patients who do not receive care that incorporates their cultural beliefs (DeWilde & Burton, 2017).This study represents initial steps in researching the theory byexploring the layering of stressors that place the patient at risk for Cultural Distress. Methods: Utilized aCross-sectional descriptive correlational analysis of intersecting identities (Structural Stressors), ethnicity-related stressors (Otherness) and ethnic-identity (Otherness) to develop understanding of the potential effects of these variables on psychological stress. Independent variables included intersecting identities, perceived ethnic discrimination, concern for stereotype confirmation, own group conformity pressure, and group membership. The dependent variable was perceived stress. Participants were also asked to define the word culture. Results: Stereotype confirmation concern, perceived ethnic discrimination, group membership, and own group conformity pressure were significantly associated with perceived stress. Intersectionality was not significantly associated with perceived stress but was significantly associated with perceived ethnic discrimination. Regression analysis revealed stereotype confirmation concern, own group conformity pressure, and group membership as significant predictors of perceived stress. Participant definitions of culture primarily fell under two themes, Collectiveness and Individualness, indicating that the way we live is highly influenced by our shared experiences, and also a product of individual choices. Discussion: Results indicated that structural stressors had no influence on psychological stress but were associated with perceptions of discrimination. The experience of otherness significantly influenced psychological stress. Additional research and tool development is needed to better understand how structural stressors may influence psychological stress.