<p> In response to the increased demand for primary care in the United States&mdash;a byproduct of a growing elderly population and insurance expansion under the Affordable Care Act (ACA)&mdash;the total number and capacities of community health centers (HCs) is expected to grow. While HCs have historically depended on physicians to deliver the majority of their care, more and more, they are shifting to non-physician clinicians, especially nurse practitioners (NPs); yet, little is known about the quality of care delivered by NPs in HCs or about the role state occupational restrictions have on these practitioners or their patients. </p><p> Using quasi-experimental methods and data from the community health center subsample of the National Ambulatory Medical Care Survey (NAMCS), this dissertation explores three distinct, but related, research questions regarding NP-delivered care in HCs&mdash;its effectiveness and comparability to physician care, the extent that tradeoffs in the quantity and quality of care are made, and the real-world risks and benefits of states easing their scope of practice restrictions. Findings, which suggest that NP care is comparable to physician care in most ways and that the quality of NP-delivered care does not significantly vary irrespective of states&rsquo; NP independence status, have important implications for policy and practice.</p>

<p> <b>Background:</b> In low- and lower-middle-income countries (LLMICs), 16% of pregnant and 20% of postpartum women experience common maternal mental health disorders, far surpassing global rates of 10% and 13%, respectively. Maternal depression is associated with poor perinatal outcomes, including maternal, newborn, and early childhood outcomes. The Edinburgh Postnatal Depression Scale (EPDS) was recently validated in Rwanda, yet maternal depression prevalence and associated factors are unknown.</p><p> <b>Objectives:</b> The primary objectives of the study are to describe antenatal depression prevalence and its associated factors.</p><p> <b>Methods:</b> This is a secondary analysis of the Preterm Birth Initiative-Rwanda randomized controlled trial of group antenatal care (ANC) data obtained between June 2017 &ndash; June 2018. Thirty-four health centers in five districts were selected. At each health center, convenience sampling was used to ascertain EPDS scores from the first five women to present for initial ANC each calendar month. A cut-off EPDS score of &ge;13 was used to define maternal depression. Multi-level simple and multiple logistic regressions were used to explore associated factors of antenatal depression. The study obtained informed consent and was approved by the Rwanda National Ethics Committee and the University of California, San Francisco institutional review board. </p><p> <b>Results:</b> Twenty-percent of women in the antenatal period screened positive for depression. In the adjusted multi-level multiple logistic regression model, family social support, age, ability to communicate with partner, and perceived stress were significantly associated with antenatal depression.</p><p> <b>Conclusions:</b> Antenatal and postpartum depression prevalence in Rwanda exceeds LLMIC averages. The authors recommend universal depression screening and treatment for pregnant and postpartum women.</p><p>

<p> The primary purpose of this clinical scholarly research project is to determine whether there are undiagnosed symptoms of depression among the residents in a small population Long Term Care facility (LTC). Caregivers at the LTC receive specific knowledge regarding older adult late-life depression and then apply said knowledge by surveying the LTC residents (LTCR&rsquo;s) using the Geriatric Depression Scale instrument (GDS-15). The secondary purpose is to determine whether the LTC caregivers perceive this training as beneficial. Using two-sample t-test statistical analysis, the results of this study indicate a positive correlation with the alternative hypothesis; the number of LTCRs with previously undetected depressive symptoms increased. H_a: &mu; LTCR with depression or delirium &ne; &mu; LTCR with depression or delirium. In this study, the number of LTCRs with symptoms of depression or delirium increased by 60.4 percent. The P (T&lt;=t) two-tail value is less than 0.001. In the literature, this difference is extremely statistically significant. The mean of the medical records examined minus the mean of the number of medical records with an indication of depression or delirium is 0.60. For a 95% confidence interval, this difference must fall between the ranges of 0.45 to 0.76. These data confirm the alternative hypothesis. </p><p> Additionally, the caregiver participant&rsquo;s satisfaction outcome survey results reported the training was substantially beneficial. </p><p>

<p> A college community health improvement plan (CHIP) focusing on the indicators of nutrition and weight status, and physical activity and fitness is designed with the goal of reducing obesity risk, improving health, and preventing chronic disease. The precede proceed model, logic model, innovative care for chronic conditions model, self-care theory, and Bandura&rsquo;s social cognitive learning theory were used as a research design framework for assessing, planning, and managing sustainability through a two-year college health clinic. The research questions were: what are the current health promotion inputs and activities in terms of environment, ecology, education, and policy and could be supplemented to improve outputs and health outcomes? An integrated review of the literature, observation of the site, regulatory investigation, and focus group sessions were the methods of data collection. The precede-proceed model provided the analytical strategies to assess initiatives and resources, and to determine supplementary initiatives and resources. Results showed that environmental, educational, administrative, and policy resources were available but limited and not well promoted. Conclusions were that health promotion, wellness staffing, and education exist, but are underutilized, under promoted, and funding is necessary. Recommendations include a wellness program, increased activity initiatives, case management, grant funding, and increased community partnerships. The contribution to nursing is to fill a gap-in-practice for health planning in 2-year colleges. The implications for positive social change are improved knowledge, sustained health behaviors, decreased amount of obesity, improved health outcomes and quality of life, decreased chronic diseases, and lower healthcare costs. </p><p>

<p> The implications of nonadherence consistently show that nonadherence or poor adherence diminishes the efficacy of ART and have resulted in the increasing rate of hospitalization, mortality and morbidity among people living with HIV/AIDS despite advancement in medicine and science. The purpose of this study was to explore the phenomenon of adherence to HIV antiretroviral regimens among HIV-infected homeless youth in California. The goal of the study was to clearly understand the perception and perspectives of the issue of adherence from the standpoint of those closest to the individuals experiencing the phenomenon.</p><p> A renowned HIV/AIDS service organization in California was selected for the study, and the staff were interviewed. The findings from the study uncovered specific facilitators and barriers to adherence faced by homeless youth living with HIV/AIDS. The study established that one of the major differences between homeless youth and the general population was their attitude to HIV/AIDS; unfortunately, most of the homeless youth in California do not regard HIV as a serious health problem. The study also found that the most serious public health problems in the county where the research study was conducted were homelessness and substance abuse and as such some of the HIV infected youth sell their HIV medications to buy street drugs, while some who are lucky to be HIV-negative wished they were positive, so they could qualify for free housing and other free financial services.</p><p> The research study concluded that the quicker homelessness is addressed among youth living with HIV/AIDS the more realistic it will be to focus on medication adherence and ultimately focus on preventing the spread of HIV in California. The research study provides direction for future multifaceted study directed towards addressing the issues of homelessness, substance abuse and prevention of the spread of HIV/AIDS among homeless youth living with HIV/AIDS disease as they are all interconnected and one cannot be solved without the other.</p><p>

Recently there has been a call for the enhancement of environmental health content in undergraduate curricula to help nurses become more familiar with environmental hazards which place their clients at risk. This survey was conducted among the 478 National League for Nursing (NLN) accredited undergraduate programs in the United States. This non-experimental, descriptive, and exploratory research was conducted to determine the following with respect to environmental health: (1) current and ideal emphasis, (2) faculty preparation, (3) competencies expected of graduates, (4) didactic and clinical contact hours allocated, (5) barriers and incentives to greater emphasis, and (6) differences among type of institution with respect to education in this topic. A mailed self-administered questionnaire was sent to the Deans of these programs. The response rate was 81.4%. Data analysis indicated that ideally 94% of respondents believed environmental health should be given moderate to substantial emphasis while only 73.4% actually provided this emphasis. As actual and ideal emphasis increased, the respondents' perception of faculty willingness to modify the curriculum to include environmental health content, faculty preparation to teach or provide clinical supervision in environmental health, and expected program graduates competencies also increased (p = 0.001). Most significant barriers to increased emphasis were an already overburdened curriculum, lack of qualified faculty to teach this topic, and lack of emphasis on the NCLEX. Factors likely to increase the emphasis were nursing faculty with expertise in environmental health, greater emphasis on environmental health on the NCLEX, and "other", most often the need for faculty development in this area. No evidence of any relationship between research questions and institutional type or size was found (p =.05). Findings contribute to nursing education by providing an assessment of the status of environmental health content in nursing education and clarify some of the complex reasons for the present neglect of environmental health in the education of professional nurses.

This study of the contextual aspects of adolescent girls, sexual behavior examines the role of choice by adolescent girls, regarding their first time ever sex. In addition the study explores the factors that contribute to girls, choice to have sex for the first time. Narrative analysis, using semi-structured interviews with open-ended questions, was used to interview seventeen sexually active girls ages fourteen to nineteen. The analysis, conducted with a feminist perspective, revealed that girls perceived they exercised choice regarding first time ever sex and that they developed moral codes to determine the subjective rightness or wrongness of having sex with a boy. The following criteria rendered having sex with a boy the “right” thing to do: (1) the length of relationship, (2) the boy's “being there” for the girl, (3) the girl's feeling of love toward the boy, (4) the girl's trusting the boy, (5) the girl's sense that this was the right boy and the right time for her to have sex, (6) the girl's curiosity about sex, and (7) the girl's taking precautions to maintain herself infection-free during sex. Analysis also revealed that girls had a partial and superficial understanding of taking precautions to maintain themselves free from infection. Ten of the thirteen girls who used condoms during their first time sexual experience abandoned using condoms during subsequent sexual intercourse with the same boyfriend. Younger girls did not use condoms to protect themselves from infection. First time sex with boys paved the way for the girls to trust the boys not to give them infections during subsequent sexual activity. Some girls relied on medical documentation that stated the boy was “clean,” and girls believed that the documentation was valid for the duration of the relationship the girls had with the boys. Key implications include the need for (1) sex education to pre-adolescent girls prior to girls becoming sexually active, (2) addressing the gaps and misunderstandings regarding sexual disease transmission, (3) accurate and complete instruction about disease prevention, and (4) training practitioners to take accurate sexual histories and to be alert to misunderstandings about disease transmission.

Driving while sleepy, drowsy or fatigued are leading contributors to road crashes. Sleepiness, drowsiness and fatigue usually occur at the end of a prolonged period of time during which an individual has been awake. Although these factors have been heavily researched, it is not clear how one of their primary causes, a prolonged total awake time (TAT), might affect driving skills such as hazard anticipation, hazard mitigation and attention maintenance, three skills that are crucial for safe driving. The first experiment investigated how these three driving skills are affected by prolonged TAT, and if so to what extent. Forty-eight participants completed two separate driving simulator sessions, one a pre-test and one a post-test. Based on the online questionnaire, participants were assigned to two different groups, namely Short-hours and Long-hours. A total of two hours elapsed between the pre-test and post-test for the Short-hours group. A total of twelve hours elapsed between the pre-test and post-test for the Long-hours group. The pre-test session was administered at 9:00 a.m. or 10:00 a.m. for both Short-hours and Long-hours groups. The post-test session was administered at 11:00 a.m. or 12:00 p.m. for the Short-hours group and at 9:00 p.m. or 10:00 p.m. for the Long-hours group. It was expected that Long-hours group would perform on average more poorly in the post-test due to a longer total awake time. In each session, participants were asked to navigate a simulated world that included twelve scenarios: four examined drivers' hazard anticipation skills, four examined hazard mitigation skills and four examined attention maintenance skills. While driving, all participants' eye behaviors were measured. The results showed that the Long-hours group drivers' hazard anticipation, hazard mitigation and attention maintenance skills were compromised. The above findings led to the development of a PC-Based Sleepiness and Fatigued Driving Evaluation and Training Program (SAFE-T) that was used to train drivers in each of the three driving skills mentioned above. The SAFE-T Program was configured to run on a standard PC so that the training could be undertaken without the need for advanced simulation by any drivers whose jobs required that they be awake and driving at the end of a long shift. The second experiment investigated if the SAFE-T Program would effectively train drivers who were awake for a prolonged period of time to maintain their driving performance in each of the three driving skills, namely hazard anticipation, hazard mitigation, and attention maintenance. Based on the online questionnaire, participants were assigned to two different groups, namely Trained (SAFE-T) and Placebo. Thirty-six participants completed a pre-test, the SAFE-T or placebo training, and a post-test. All participants were in the Long-hours condition in this experiment, which is a total of twelve hours (the time that elapsed between the pre-test and the post-test). The pre-test was administered at 9:00 a.m. or 10:30 a.m., the training was administered right after the pre-test, and the post-test was administered at 9:00 p.m. or 10:30 p.m. The results showed that participants who were given SAFE-T training performed better during the post-test than during the pre-test in all the three skills. In contrast, the participants who were given Placebo training performed worse during the post-test than during the pre-test in all the three skills.

The purpose of this exploratory study was to investigate Chinese junior college students' condom use intentions to prevent HIV/AIDS. The following research question was addressed: How is knowledge about HIV/AIDS risk, attitudes, subjective norms, self-efficacy, prevention expectancies, and prior condom use related to condom use intention among college students? Questionnaires and semi-structured interviews were employed in this study. Variables for the survey were selected from the Theory of Reasoned Action and the Self-Efficacy Theory. A questionnaire was modified and translated from an English instrument and back-translated to ensure cultural relevance and sensitivity. In addition, twenty students were purposely selected for interviewing among those who indicated they had had sexual encounters. Of all the students in the survey sample, 29% males and 9% females admitted having sexual experiences. Data analysis was based on the subsample (N = 302) who had sexual experience. The subjects' knowledge of AIDS-related risk behavior produced an average score of 68% correct responses based on true-false questions. Knowledge, however, was not significantly related to any of the other variables. Logistic regression analysis was employed to analyze students' intentions for condom use to prevent HIV/AIDS. For all students, prior condom use was the most important determinant of intention for future condom use. For male students, the estimated odds ratio of prior condom use and self-efficacy were significantly associated with intention to use condoms. This finding suggests that the actual practice to master the skill of condom use is critical. For female students, prior condom use and attitudes significantly predicted the intention for condom use. Themes from the interview data were students' general HIV/AIDS knowledge, sources of sex education, perceived risk of acquiring HIV/AIDS, strategies for managing risk, discussion content and the influences of parents, siblings, friends, and sexual partners on students' personal norms. The implication from the interview data was that prevention of pregnancy was the most important factor for students to use condoms, rather than fear of contracting STDs or HIV/AIDS. Thus, suggestions for education programs are discussed.

An original AIDS Attitude Scale was distributed to registered nurses employed in intensive care, medical, medical-surgical, and surgical units of four western Massachusetts hospitals. 439 completed questionnaires, representing a 64.6% response rate, were returned by mail. Results of data analysis indicated that nurses would be more cautious than necessary in using precautions while handling body secretions of or doing nursing procedures with patients with AIDS. Nurses form a small community hospital and those with less experience in caring for AIDS patients would be more cautious than those from a teaching medical center and those who had cared for six or more AIDS patients. Two-thirds of the nurses would feel a great deal of stress in caring for seriously ill adult AIDS patients. Significant differences in mean stress scores for caring for patients with five diagnoses indicate that AIDS patients evoke the most amount of stress, and those with extensive burns, multiple trauma, metastatic cancer, or hepatitis B evoke decreasing amounts of stress, in that order. More than one-half of the respondents indicated that more than one-half of their family members/significant others had expressed concern about their becoming infected with HIV as a result of caring for AIDS patients. Teaching hospital respondents reported a significantly greater percent of concerned persons than did those from community hospitals. Multiple regression analysis of the twelve Likert items indicated that having a family member/personal friend with AIDS, having a greater percent of concerned persons, being male, or being employed in a small community hospital were associated with a less favorable attitude about caring for AIDS patients. The coefficient alpha (Cronbach's alpha) for the Likert scale was.72. Factor analysis of the Likert scale identified five subconcepts: stigma; pregnancy concern; mortality/prognosis stress; resource utilization; and HIV-status knowledge. Study results are limited to the respondents. Implications of the results for health services managers include implementation of a multi-faceted educational and support program for nurses caring for AIDS patients. Suggestions for further research include replication of the study with nurses in different clinical specialties, settings, and geographic regions.