American Heart Association officials and other expert cardiologists recommend omega-3 (n-3) dietary supplementation for the secondary prevention of cardiovascular disease, a prevalent health problem in the United States. Physicians' lack of understanding of possible n-3 preventive health benefits results in underprescribing n-3 dietary supplements and lower n-3 dietary supplement product sales. N-3 dietary supplement marketers do not understand physician n-3 prescribing decision criteria enough to optimize high-impact communication to physicians to increase n-3 dietary supplement product use. The purpose of this phenomenological research study was to improve n-3 marketers' understanding of how physicians reach decisions to prescribe or recommend products including n-3 dietary supplements. Argyris' ladder of inference theory provided the study framework to facilitate understanding physicians' decision criteria. Rich data collected and analyzed from 20 primary care physician interviews in Kentucky, Indiana, and Tennessee revealed physicians use similar decision criteria for drugs and n-3s. Three essential influencers of physician decisions included clinical evidence, personal experience, and cost. Other influencers were opinions of peers, pharmaceutical representatives, samples, direct-to-consumer advertising, and knowledge of dietary supplements. Study outcomes may inform pharmaceutical marketers regarding presentation of clinical evidence, cost emphasis, and pharmaceutical representative skills and may facilitate competitive advantage for n-3 marketers. The social benefit of this study is improved physician understanding of n-3s may result in more accurate and appropriate prescribing to augment positive health outcomes.

Growing media attention and a high diagnosis rate of autism places significant demand on the service industry to provide qualified staff to work with individuals who have autism. Discrete trial instruction (DTI) is one of the most sought-after treatment approaches for those individuals. However, there is a gap in research regarding the efficacy of training methods for those who train direct staff to implement DTI. This quantitative study used an applied behavior analysis basis, deriving from foundations of behavior theory, to compare the abbreviated feedback form (AFF) to the lecture test model (LTM) to understand which will improve direct staff's ability to implement DTI more efficiently from baseline. The AFF provided for trainees a list of skills to implement tasks that have multiple steps. The LTM provided trainees a lecture of skills to understand basic applied behavior analysis, autism, and DTI. Four participating staff's baseline and training data were analyzed by comparing their scores to the set criterion from the AFF. The data were analyzed by both the program supervisor and the researcher, with inter-observer agreement reached. Using a single-subject, AB design, data demonstrated that staff who were trained using the AFF had significant improvement from baseline, compared to staff trained using the LTM. Supervisors who use the AFF to more efficiently and rapidly train staff may decrease the time gap between service recommendation and implementation, making needed treatment more readily available and efficacious to children diagnosed with autism. Improvements in staff skill set will likely have a direct correlation on the improvements and long term outcomes for those being treated.

As the percentage of school children with chronic conditions such as diabetes continues to rise, funding for school nurses to keep those students healthy and safe is decreasing. This dissertation includes three studies: (1) a systematic review of the literature on the role and impact of American elementary school nurses, (2) a focus group study that further examined the role of Kentucky school nurses and described their reaction to a new regulation that necessitates delegation of diabetes-related nursing tasks to unlicensed assistive personnel (UAP), and (3) a quantitative study that examined Kentucky school nurses’ past behaviors and future intentions regarding the delegation of diabetes-related tasks. A systematic review of the literature revealed that activities of school nurses can be conceptualized into four major areas: (a) health promotion and disease prevention; (b) triage and treatment of acute issues (e.g., injuries and infectious diseases); (c) management of chronic conditions; and (d) psychosocial support. School nursing activities are associated with increased attendance, higher quality schools, and cost savings. Focus groups in three regions of Kentucky found that Kentucky school nurses fulfill the same major roles as their counterparts across the nation, and face similar challenges such as lack of time, limited resources, language barriers, and communication issues with families. School nurse participants described their biggest impact on students as identifying and addressing students’ physical and psychosocial barriers to learning. While recent legislation was passed in Kentucky necessitating the delegation of insulin administration to UAP, school nurses had not experienced many changes at the time of the focus groups. However, some nurses said that their districts were not planning to delegate insulin administration and intended to keep a nurse in every school. Others appreciated the prospect of having more trained staff in schools to recognize signs of distress in chronically ill students. A statewide survey of 111 Kentucky school nurses indicated that nurses’ past delegation behaviors and future intentions related to delegation are rooted in the level of skilled decision-making that must occur and the risk to the student if the wrong decision is made. Unfortunately, school nurses’ intentions to delegate higher-stakes tasks (e.g. carbohydrate counting, insulin dose verification, and insulin administration) were significantly stronger than their support for (attitude related to) delegation of those tasks, which is disconcerting both for the safety of students as well as for the liability retained by delegating nurses. This disparity between support and intentions indicated that school nurses anticipate that they will have to delegate certain tasks to UAP despite their discomfort with delegating them, most likely due to high workload and lack of resources. Additional studies should be undertaken to determine the impact of legislative changes on the delivery of school health services in Kentucky and other states, particularly once school districts and nurses have had adequate time to adjust to new laws. Such studies should investigate to whom nurses are delegating health services, what tasks are being delegated, and the extent and process of training that UAP receive. Future surveys should utilize perceived behavioral control items that assess situational control (e.g. policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Researchers must further explore the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks? Kentucky school nurses are champions of health promotion for children, not only in their provision of health services and health education, but also in the area of school health policy. School nurses should train UAP so that more school staff can recognize signs of distress in students with diabetes, but at the same time should continue to advocate and seek funding for a nurse in every school with the help of the Every Student Succeeds Act.

Despite increased awareness about patient safety and quality of care, errors and adverse outcomes occur frequently in clinical practice. An estimated 10% of the 35.1 million U.S. hospital patients suffered injuries caused by medical errors; the most common were medication errors, which accounted for more than 50% of all medical errors. Work-related stress is associated with medication errors for health care professionals (HCP) in Saudi Arabia (SA) hospitals; however, the specific types of stressors and their effect on the level of medication errors have not been studied in SA. The purpose of this quantitative correlational study was to examine the relationship between the overall level and sources of work-related stress using the job stress scale on the level of medication errors for a group of 269 HCPs working at King Abdul-Aziz Hospital (KAH) in SA. The theoretical framework for this research was the Donabedian patient safety model, which relates healthcare quality to personal, environmental, and organizational factors. Binary logistic regression analyses indicated there was no relationship between overall levels of stress and medication errors. However, specific sources of work related stress such as disruption to home life, excessive workload, and night/weekend call duties were associated with a significant increase in the medication error rate, while pressure to meet deadlines and difficulties with colleagues was associated with a significant decrease in the medication error rate. Positive social change implications include how understanding the impact of work-related stress on medication errors by SA HCPs may lead to specific interventions to reduce medication errors and improve patient care.

Ample research has been found to suggest that there is no substitute, either nutritionally or emotionally, that can replace the benefits of human milk for human infants. Despite this recognition, the attitude still exists that infant formula is a reasonable alternative. The American Academy of Pediatrics (AAP), World Health Organization (WHO), and United Nation Children's Fund (UNICEF) share policy statements endorsing human milk as the optimal infant nutrition for the first 15 months. Accordingly, WHO and UNICEF launched The Baby-friendly Hospital Initiative established in 1991 to protect, promote, and support breastfeeding. Despite this unilateral support of breastfeeding, nursing and physician educational curriculums do not include lactation education, which limits the knowledge of those who provide care to the mother and newborn dyad. The purpose of this project is to promote staff lactation education and training on the infant feeding practices by encouraging breastfeeding in a hospital setting. This project includes lactation education and hands-on training for staff. A 20-hour didactic lactation education course will meet the requirements to ensure that staff training will assist in supporting patients with the early initiation of breastfeeding. Furthermore, training will include clinical competencies to evaluate the knowledge, practice patterns, and confidence of the staff. Lactation education for providers will be provided through an online course designed to improve their ability to support breastfeeding among their patients. The result of this project will assist hospital leadership to determine specific education and training for staff in increasing exclusive breastfeeding rates among their patient population.

The widespread use of highly active antiretroviral therapy (HAART) has resulted in longer lifespans for HIV seropositive women in the United States, during which preventive health care is recommended. Failing to complete recommended cancer screening tests can result in cancer being diagnosed at a later stage with a poorer prognosis. The purpose of the study, based on the ecosocial theory, was to describe the sociodemographic and clinical variables of HIV seropositive women who failed to complete recommended screening tests for breast, cervical, and colorectal cancers, and determine if the presence of hypertension, obesity, diabetes, depression, or tobacco use impacted the completion of these screening tests. The electronic medical records of 142 HIV seropositive women were reviewed. Univariate analysis, bivariate analysis, and logistic regression were conducted to create a model associated with the completion of preventive health care screening tests. For breast cancer, cervical cancer, and colorectal cancer, 69%, 71.8%, and 69.7% failed to complete screening, respectively. Number of years living with HIV infection and HIV stage were associated with breast cancer screening; distance between residence and health care facility, and HIV stage were associated with cervical cancer screening; and age and marital status were associated with colorectal cancer screening. Addressing issues related to the completion of cancer screening tests over the lifespans of HIV seropositive women can result in positive social change by preventing disease and disability, which can negatively impact these women, their families, and their communities.

Epidemiologic surveillance indicates an increased susceptibility to obesity among children with special health care needs (SHCN) in comparison to children without. The present study investigated this disparity in weight severity between both groups, with a focus on the provision of obesity management counseling by physicians. This study consisted of a retrospective medical record review that acknowledged the effect of patient-provider interactions on health behaviors and risk perceptions. An independent sample t test compared the incidence of clinician-initiated obesity management counseling received by children with SHCN to that which was received by children without SHCN. This t test revealed a statistically significant difference between the weight management frequency received by youth with SHCN (M = 1.0, SD =.46498) and the weight management frequency received by youth without SHCN (M = 2.0, SD = .74975), t(100) = 7.826, p = .000, α =.05 over a 2-year timeframe. Bivariate correlation analysis validated a correlation between weight severity among children with SHCN and the incidence of clinician-initiated obesity management counseling. The results indicated a small but significant association between weight severity and weight management frequency among children with SHCN, r(50) = .287, p = .044, α =.05. These results support the need for a transformation in the delivery of preventive health services for children with SHCN, such as providing clinician-based obesity management strategies and increasing access to validated diagnosis-specific preventive health screening tools. These results promote positive social change by informing efforts to improve health outcomes and decrease health disparities experienced by people with SHCN.

Smoking during pregnancy remains a significant public health issue despite knowledge about the adverse maternal and fetal health effects. This research had six purposes: identifying effective smoking cessation strategies for low income pregnant women; identifying characteristics of Kentucky women who smoke during pregnancy; estimating the role of smoking on birth outcomes in Kentucky; exploring the impact of tobacco reduction on birth outcomes; identifying the characteristics of women participating in the Giving Infants and Families Tobacco-free Starts (GIFTS) pilot program; and evaluating the impact of GIFTS on smoking status and birth outcomes. Seven randomized controlled trials targeting low income women with smoking cessation interventions identified social support and incentives as promising strategies. Only one study focused on women living in rural settings. Live birth certificate data from 2004-2008 revealed that 26% of Kentucky women reported smoking during pregnancy. Continuing to smoke approximately doubled the odds for low birth weight (LBW) [Estimated Odds Ratio 1.95 (95% Confidence Interval 1.87-2.03)] and no breastfeeding initiation (NBI) [1.93 (1.87-1.98)] versus no pre-pregnancy smoking. Continuers also had higher odds for preterm birth (PTB) [1.25 (1.20-1.29)] and neonatal intensive care unit admissions (NICU) [1.20 (1.14-1.26)]. Reducers and quitters had increased odds of LBW and NBI. The probability of quitting relative to the probability of continuing was increased for women aged less than 25, non-White, Hispanic, graduate degree, obese and "other" payor source for the delivery. The GIFTS program targeted pregnant women receiving local health department services who reported recent or current tobacco use. Significantly increased odds of participation were identified for women reporting 1-5 [2.05 (1.06-3.94) ], 6-10 [2.06 (1.10-3.83)] and ≥11 [2.17 (1.12-4.20)] cigarettes per day compared to those reporting no cigarettes. Women with one [1.55 (1.07-2.24)] or two [1.83 (1.21-2.76)] previous quit attempts also had increased odds for participation compared to those with no quit attempts. GIFTS participants were significantly less likely to have preterm infants (p=.0369) than a matched comparison group. No significant differences were found on tobacco cessation, tobacco reduction or cessation, LBW, NICU, or NBI. This research has implications for future cessation efforts as well as policy development.

Household food security status in rural areas is a significant issue facing caregivers as positive health outcomes depend on appropriate access to healthy foods necessary to lead an active life. Access and affordability of healthy foods are two mediating factors of household food security that may be improved to ultimately increase rates of food security and overall health status among rural, low income populations. The purpose of the study was to examine the factors of access and affordability of nutritionally adequate food sources in one rural community in relation to food security status through the perspective of its caregivers. In general, populations suffering from low rates of food security report lower access to healthy foods and the inability to afford healthy foods. The study utilized a primarily qualitative approach; however, thirty-one participants were initially categorized by levels of food security by the US Household Food Security Survey Core Module as a quantitative measure. Twelve participants who were classified as food insecure and were caregivers to children under the age of 18 responded to an in-depth interview focusing on the factors of access and affordability. Twenty-six (84%) of the thirty-one food pantry clients who completed the initial survey were classified as food insecure. Open-ended interviews of participant perceptions of access and affordability to health foods in relation to food security revealed several major themes titled transportation and physical ability challenges, key issues in store choice, cost barriers in food shopping, strategies to maximize food dollars, and factors involved in food choice. The results of this study, while they must be interpreted with caution, suggested there were multiple systems interacting that mediated the problem of food insecurity in this rural area through the perception of low income caregivers. The data can be used to improve health promotion programs and inform public health policies that can have a positive impact on overall health in rural areas.

The purpose of the present study was to examine the relationship between mindfulness and its link to sexual satisfaction and relationship satisfaction. Data were collected from 809 individuals (18.8% bisexual, 60.7% straight, 19.2% gay/lesbian) in romantic relationships. Participants completed an online survey to measure mindfulness (five facets: observing of experience, describing with words, acting with awareness, non judging of inner experience, non reactivity to inner experience), sexual satisfaction, and relationship satisfaction. Results from two multivariate analyses (predicting sexual satisfaction and relationship satisfaction) revealed that relationship satisfaction is significantly predicted by three of the five facets of mindfulness – acting with awareness, describing with words, and non judging of inner experience. Sexual satisfaction was significantly predicted by the non judging of inner experience facet of mindfulness. Non judging of inner experience was the only facet that significantly predicted both relationship and sexual satisfaction. These findings indicate that when individuals are able to take a non-evaluative stance towards their sensations, cognitions, and emotions, they are more likely to be satisfied. Future research and clinical intervention for improving satisfaction may benefit from focusing on mindfulness related to the non judging of inner experience. Implications for clinical practice and future research will be discussed.