The lesbian, gay, bisexual, and transgender (LGBT) community is a unique population that has specific health issues and health care needs associated with lifestyle behaviors that increase risk for certain diseases. Health concerns include mental and behavioral health, issues associated with gender identity and relationships (i.e. intimate partner violence), sexually transmitted infections, and chronic illnesses. The research suggests poorer health outcomes for the LGBT population compared to heterosexual and/or cisgender counterparts. Most research conducted with LGBT populations occurred in more populated urban settings with very few studies focusing on this population in the rural context. Consequently, there is a paucity of information on the health care concerns of the rural LGBT population. Considering the information gap, this integrative review of 14 research articles focused on health-related issues of the LGBT population in rural regions. The findings revealed rural LGBT persons experience disparities in accessing health care and support services; coupled with health care providers who often were not culturally competent; and, sometimes, unfamiliar with evidence-based health care protocols when caring for the LGBT patient. Implications for nursing research, education, practice, and policy and study limitations are highlighted.

<p>The purpose of this dissertation is to discuss and evaluate processes and institutional structures that influence relationships between Aboriginal communities and government in the development, implementation, and evaluation of health policy. It explores the changing nature of Aboriginal health policy and politics in Canada and examines the shift to self-determination that has transpired in Canada’s Aboriginal health policies focusing on their application to Aboriginal peoples. This dissertation examines two Aboriginal health policies in Canada: the federal health transfer policy and Ontario’s Aboriginal Healing and Wellness Strategy. Both policies are intended to improve health at the community level by supporting the development of community-based and culturally appropriate health programs. Thus, using community-based research methods, this dissertation maps some of the key political stakeholders in Aboriginal health policy, from local level community members and health representatives to peak provincial and federal Aboriginal organizations, to the offices of ministers in Canadian parliament. I reflect upon the processes and institutional structures that shape relationships between the Aboriginal community-controlled health sector and government.</p> <p>I examine several First Nations communities in northern Ontario involving both federal and provincially supported initiatives to illustrate the strengths, weaknesses and paradoxes that surface from the implementation of locally controlled health programs. I contrast these efforts with a second First Nations community in Manitoba that operates solely under the federal health transfer policy. I juxtapose these two communities to assess whether additional layers of community-controlled initiatives make tangible differences to community wellness; particularly for Aboriginal peoples living off reserve. This dissertation is being written under the theoretical assumption that governance and community wellness are intrinsically linked. Arguably, there is a definitive correlation between self-determination and community well-being; self-determination may be a determining factor in improving conditions for Aboriginal peoples and understanding resiliency.</p> <p>This dissertation is about a long lasting colonial legacy of social inequalities in Aboriginal health but also about the incredible successes in Aboriginal health. It is also about the many challenges of Aboriginal representation and self-determination in the context of contemporary Canadian society.</p> / Doctor of Philosophy (PhD)

Adults aged 65 years and above have grown substantially over with past decade. However, the chance of developing multiple comorbidities only increases with age. Because elderly residents of rural Appalachia often encounter barriers to healthcare, rural nurses, providers, and policy makers must overcome physical and structural barriers, but also gain a more in-depth understanding of the personal and cultural attitudes impacting the use of new and innovative forms of healthcare delivery. With a slow and variable uptake of telehealth adoption in rural Appalachia, and in the presence of well-documented medical mistrust, this study was designed to better understand the degree of medical mistrust existing in the elderly of rural Appalachia and to assess if medical mistrust may be inhibiting efforts related to telehealth acceptance. A correlational design was utilized administering the Medical Mistrust Index (MMI) and Technology Acceptance Model (TAM) questionnaire via electronic survey to those age 65 years and above living in rural Appalachia. Deemed well-established and validated, the MMI measures medical mistrust from a broader perspective, while TAM assesses telehealth acceptance in terms of perceived usefulness, perceived ease of use, and overall attitude towards telehealth as a technology. Demographics of gender, income, education, and previous telehealth experience were compared to MMI and TAM scores. The study revealed a moderate level of medical mistrust and telehealth acceptance among the elderly of rural Appalachia. A statistically significant negative relationship was found between MMI and TAM for those reporting previous telehealth experience, and among all demographics, with the strongest correlations found among females and participants of lower education. Elderly rural Appalachians have a rich social and cultural history, but past experiences and long-held beliefs have resulted in medical mistrust and slow telehealth uptake. Stakeholders have a responsibility to meet individuals where they are understanding that elderly residents of rural Appalachia may not be ready or fully prepared to incorporate telehealth into their management of care. However, quality rural nursing practice and continued research has the ability to evolve to meet the needs that exist among those of advancing age with limited healthcare resources such as those found in rural Appalachia.

External and internal funding is a way that nurse scholars can support research and scholarship activities. Often, programs are supported by a combination of internal and external funding to support projects. External funding through competitive grants is a valuable way to fund initiatives and to expand services. However, these applications commonly require a detailed and complete budget that will provide a framework to fiscally plan for program activities – which can be daunting to novice grant seekers. There is a scarcity of information in the literature on the framework for the development of a program budget or how to begin, which can be a challenge to those new to this process. A well-prepared and developed budget supports the success of an external funding application and serves as the framework to fiscally support and optimize activities. The purpose of this presentation is to provide nurses the basic information on how to develop a budget for external and internal funding applications.

It is widely supported that there are significant, positive relationships between the occurrence of some mental health symptoms and physical illnesses. Research indicates that the burden experienced by those with a physical and mental illness are magnified compared to individuals who do not experience an illness. More specifically, one of the burdens experienced by individuals is the monetary burden of affording the necessary health services to properly manage their illness. This study attempts to reveal a difference between mental health symptom count for individuals who do and do not experience difficulty affording health care for their physical problems. The first hypothesis states that the indication of medical problems will be associated with greater mental health symptoms. The second hypothesis states that the relationship between medical concerns and mental health symptoms will be moderated by difficulty affording health services. Lastly, the third hypothesis states that the indication of unhealthy behaviors, such as smoking and irregular exercise, will be associated with greater mental health symptoms. All data used in this study is archived data that was gathered by the Institute for Rural Health’s Mobile Health Units during free community health fairs from September 2012 to February 2014. The first hypothesis was supported because the incidence rate of mental health symptom count was increased with the presence of some physical problems. These findings supported previous research that indicated that the presence of physical illness increases the chance of developing a mental illness. The study results revealed that the second hypothesis was not supported since difficulty affording health services did not have a significant effect on the relationship between indicated physical illnesses and mental health symptom count. Previous research reports that there is monetary burden for individuals who experience a physical or mental illness when accessing appropriate health services. This research aimed to explore if that burden would significantly affect the relationship of those illnesses. Lastly, the third hypothesis was supported because mental health symptom count incidence rate was found to increase for individuals partaking in negative health behaviors, such as smoking, and decrease for individuals partaking in positive health behaviors, such as exercising.

<p><b>Background</b><br></p> <p>More than 90% of individuals aged 65 years or older in the United States (US) are taking at least one prescription medication, and more than 40% are taking five or more prescription medications. The potential for non-adherence and risk of medication therapy problems (MTPs) increases with the use of multiple medications. To enhance patient understanding of appropriate medication use, improve medication adherence, and reduce MTPs, the Centers for Medicare & Medicaid Services (CMS) launched Medication Therapy Management (MTM) services as part of Medicare Prescription Drug (Part D) policy; however, “best practices” for achieving positive MTM outcomes are not well understood.</p><p><br></p> <p> </p> <p><b>Objectives</b></p> <p>This study had two objectives. The first objective was to identify and explain reasons for concordance and discordance between a) consistently high, moderate, and low performing pharmacies and b) pharmacies that improve or worsen in performance overtime. The second objective was to generate hypotheses for strategies that contribute to community pharmacies’ ability to achieve high performance on widely accepted MTM quality measures. </p><p><br></p> <p> </p> <p><b>Methods</b></p> <p>This comparative mixed-methods, case study design incorporated two complementary conceptual models. First, an adaptation of the Positive Deviance (PD) model explains reasons for deviations in MTM quality measure performance among community pharmacies and informs study design. Second, the Chronic Care Model (CCM) guided data collection and analysis. Data consisted of pharmacy/staff demographics and staff interviews. When appropriate, quantitative and qualitative data were analyzed within and across pharmacy MTM performance (i.e., high, moderate, low) or change-in-performance (i.e., consistent, improved, worsened) categories using descriptive statistics and cross-tabulation respectively. MTM performance component measures used to evaluate and rank pharmacy MTM performance mirrored measures under Domain 4 (Drug Safety and Accuracy of Drug Pricing) of the 2017 CMS Medicare Part D Plan’ Star Rating measures. This study was approved by the Institutional Review Board for the Purdue University Human Research Protection Program. </p><p><br></p> <p> </p> <p><b>Results </b></p> <p>Across the sample of eligible pharmacies (N = 56), MTM performance composite scores varied by 21.3%. Of the five component scores, the <i>Comprehensive Medication Review (CMR)</i> component score had the highest percent variation (88.3%). Pharmacy staff at 13 pharmacies of the 18 pharmacies selected as case study sites participated in interviews, yielding a 72.2% case pharmacy participation rate. Of the 13 pharmacies, five were categorized as high performers, four were moderate performers, and four were low performers. Of the 39 pharmacy staff approached across all pharmacies, 25 participated in interviews, yielding a 64.1% participation rate. Interviewees included 11 pharmacists, 11 technicians and three student interns. Eight strategies were hypothesized as positively (7) or negatively (1) contributing to pharmacies’ MTM performance. Hypotheses generated were organized by CCM elements and included: <i>Delivery System Design (DSD)</i> – Having a high degree of technician involvement with MTM activities; Inability to meet cultural, linguistic, and socioeconomic needs of patients (negative); Having sufficient capacity to provide CMRs to patients in person compared to telephone alone; Pharmacy staff placing high priority on addressing MTM activities<i>; Clinical Information Systems (CIS) </i>– Faxing adherence-related MTP recommendations and calling providers on indication-related MTP recommendations; Technicians’ use of CISs to collect/document information for pharmacists; Using maximum number of available CISs to identify eligible MTM patients; <i>Health System Organizations (HSO) </i>– Strong pharmacist-provider relationships and trust. No hypotheses were generated for the remaining three CCM elements.</p><p><br></p> <p> </p> <p><b>Conclusions </b></p> <p></p>A total of eight strategies were hypothesized as contributing to community pharmacies’ ability to achieve high performance on MTM quality measures. Notable strategies were related to three of the six chronic care model elements. Future research should engage stakeholders to assist with prioritizing hypotheses to be statistically tested in a larger representative sample of pharmacies.

Tobacco use is one of the most preventable sources of death and disease, and yet remains a worldwide problem. With the rising costs of healthcare, the focus of efforts to control them has honed in on lifestyle behaviors that contribute to the escalating costs. Within the scope of this scrutiny, the prevention or cessation of smoking and tobacco usage has become a global priority and a major focal point of worldwide anti-tobacco initiatives. The World Health Organization (WHO) has identified cessation interventions by health care professionals as a crucial factor in successful patient smoking cessation, and studies have shown that personal smoking behaviors by health care professionals are a barrier to effective smoking cessation interventions by those professionals (Lally et al., 2008; Radsma & Bottorff, 2009). This knowledge fueled the creation and distribution of global surveys by the WHO, the Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) to investigate the prevalence of smoking behaviors in health care professionals and in health care students (“Global Health Professions,” 2014; “WHO/CDC Global,” 2014). This study utilized the Global Health Professions Student Survey. The current study investigated the prevalence of smoking in nursing students of all educational levels at East Tennessee State University, with the expectation that the percentage of students who currently smoke would be substantially lower than that of students who do not smoke. The survey also investigated attitudes towards the role of health professionals in patient smoking cessation and towards personal smoking behaviors.

Transitioning to the father role can be complex and stressful and fathers may not be fully prepared to assume the father role. Since fathers have little formal preparation for becoming a father, they may need more social support resources to support their adaptations to the father role. In addition, fathers are instrumental in supporting mothers’ breastfeeding and other infant feeding decisions, but may experience difficulties with infant care tasks, such as feeding and providing care to their infant. Studies show that many fathers want to be productive and nurturing in the father role but little is known about fathers’ parenting knowledge and needs. Therefore, the purpose of this study is to describe the social support resources of fathers with infant feeding and related parent educational learning needs during the first year after birth. Cross-sectional data was obtained for this descriptive, exploratory study by using a questionnaire and semi-structured interviews. Descriptive statistics were used to analyze questionnaire findings and directed content analysis was used to analyze the qualitative data. Since there is little evidenced-based literature on social support and parenting knowledge and needs of fathers in general, the study design was descriptive, exploratory and included new and experienced fathers. The study was guided by Bandura’s Self-Efficacy Theory. The findings reported in this study originated in a larger study on social support needs of urban fathers with infants during the first year after birth. Thirty experienced and new fathers were recruited from community organizations that offer services to low-income families in a southern part of the United States. The mean age range of the fathers was 30 (SD = 5) and 60% were experienced fathers and 40% were new fathers. The majority of the fathers were single (67%), Black (90%), had some or completed high-school education (81%) and 85% reported low annual incomes of less than $20,000. Most infants were bottle-fed (73%) and all infants were between 2-12 months. Inclusion criteria included being 18 years old with an infant that was born full-term. The study was reviewed and approved by the university internal review board. Findings revealed most fathers were confident with feeding their baby, however, some fathers were not confident because they were afraid to handle their baby due to the baby’s size or felt awkward when holding the baby. When fathers had difficulties with feeding their babies, they primarily asked family and friends for advice. Other resources included the internet and healthcare professionals. Fathers reported positive and negative attitudes towards breastfeeding and reasons why breastfeeding was stopped. After the baby’s birth, fathers reported the majority of parent educational learning needs related to how to take of infant, normal infant behavior, basic, daily care, and recognizing signs and symptoms of illness. At time of interview, the majority of parent educational learning needs related to how to cope with a difficulty baby, accessing positive parenting tips and resources, being responsive to the infant, coping with being a new father, and recognizing signs of depression. Recommendations for practice and research will be provided.

Adolescents often make adult decisions regarding their lifestyle and behavior with little support from their family and community. In this study the researcher examined the difference in risk-taking behaviors between genders and the role that families and communities play in reducing risk-taking behaviors. In the study I further analyzed self-reports of numbers of development assets those students reporting participation in high-risk behaviors. Method: Data were obtained from a sample of convenience of (N=82) 12th grade students. Behaviors and attitudes were examined using the Search Institute’s Profiles of Student Life survey. Results: Chi square was used to test for significant differences in risk-taking behaviors between genders and levels of developmental assets. Males were more likely than females to participate in alcohol and substance use χ2 (1, N=82) = 63.95, p <0.05 and more likely to participate in violent risk-taking behaviors: physically hurt someone once or more in the last twelve months χ2 (1, N=82) = 22.73, p<0.05, used a weapon to get something χ2 (1, N=82) = 44.45, p<0.05, been in a group fight once or more in the last twelve months χ2 (1, N=82) = 29.33, p<0.05, carried a weapon for protection χ2 (1, N=82) = 23.78, p<0.05, and threatened physical harm to someone χ2 (1, N=82) = 46.2, p<0.05. Females were more likely to participate in sexual intercourse than males χ2 (1, N=82) = 214.08, p<0.05 and to have hit someone once or more in the last twelve months χ2 (1, N=82) = 11.53, p<0.05. In the area of risk-taking behaviors related to developmental assets, students who participated in the problem behaviors had fewer developmental assets than those not participating in the behavior. The exceptions to this were using a gun to get something from a person χ2 (1, N=82) = 72.4, p<0.05 and carrying a gun for protection χ2 (1, N=82) = 30.63, p<0.05. Conclusions: Findings from this study emphasize the need for community-based programs that enhance youth bonding with family and community. Furthermore, it reinforces the national goals aimed at reducing risk-taking behaviors such as alcohol and substance use, early sexual intercourse, and youth violence. Programs aimed at prevention and intervention that address the specific needs of males and females are recommended.

Alarming rates of suicide among production farmers have prompted researchers to investigate factors associated with depressive symptoms among this population. Aspects of farm life and farming can contribute to higher levels of depressive symptoms. Higher levels of depression can also increase an individual’s risk of injury and development of chronic disease, impacting overall quality of life. Despite the approximate 3.5 million farm women in the U.S., current research has focused on the male farmer. Men and women have different responses to stressors, and women in general have a higher prevalence of depressive symptoms. Farm women can be further subjected to stressors associated with farming as an occupation and their gendered role within the agrarian culture. The large number of farm women affected, the relationship of chronic depressive symptoms on health and quality of life, the lack of current research available, and the rising rates of suicide and depressive symptoms among farmers emphasize the need for further investigation of farm women and depressive symptoms. The overall purpose of this dissertation was to 1) explore the current state of the science of farm women and depressive symptoms and identify variables commonly associated with depressive symptoms among farm women, 2) identify variables influencing levels of depressive symptoms within farm women aged 50 and over and identify differences between those women with high depressive symptoms and those with low depressive symptoms, and 3) establish the reliability and validity of the 12-item John Henry Active Coping Scale (JHAC-12) within the sample. A systematic review of the literature revealed that there is a need for more research with strong study designs regarding farm women and depressive symptoms within the context of their environment, culture, and occupation. The review identified multidimensional factors from farm women’s lives that influence their level of depressive symptoms. Farm women’s ethnicity, the agrarian culture, family and social relations, as well as specific demographics were identified as key variables associated with an increased risk of higher depressive symptoms. Because of the identification of the multi-dimensional factors, the use of the Modified Biopsychosocial Model (MBPS) was selected as a framework for continued research as it depicts the interrelationship between the factors and their influence on farm women’s depressive symptoms. The MBPS was applied to data from 358 farm women aged 50 and older from a larger cohort study, and a secondary analysis was performed. Multivariable binary logistic regression was used to identify those variables associated with depressive symptoms among farm women. Depressive symptoms were predicted by race/ethnicity, years of education, adequacy of income for vacation, perceived health status, perceived stress score, and active coping score. Significant differences between those farm women with low CES-D score (< 16) and those with high CES-D score (≥ 16) were noted. Race/ethnicity, years of education, adequate income for vacation and retirement, reported health status of fair or better, perceived stress score, active coping score and satisfaction from farm work were all significant between groups. Women who were non-White, had less education, reported income not adequate for vacation or retirement, reported poor health, higher levels of perceived stress, lower levels of active coping and who were not satisfied with farm work were more likely to be in the high CES-D group. A principal component analysis with direct oblimin rotation in a sample population of older farm women (n=458) identified two dominant themes of the JHAC-12: “commitment to hard work” and “self-efficacy.” The instrument component structure reflects the culture of the agrarian society. In the two-component solution, 2 items were removed from the scale after revealing low values of communality (< .3). The item reduction resulted in more refined scale, increasing explained variance by 4.1% with less items. Cronbach’s of the JHAC-12 (α = .78) and JHAC-10 (α = .76) indicated high levels of reliability for both scales. Rotation of the items resulted in a simple structure with high loadings within items, no major-cross-loadings and little correlation between components (r = .29), supporting both convergent and discriminant validity in this population. The ability of the JHAC to encompass the socio-culture aspects of active coping among farm women and obtain a quantifiable result supports the JHAC as an important tool to utilize in future studies of depressive symptoms and farm women with use of the JHAC-10 in future studies of farm women decreasing the burden of the participants. Although there are limitations within each document, each section adds to the science of farm women and depression symptoms and provides directions for future research. The major gaps identified were: 1) the need for current research with stronger study designs, 2) studies of farm women across their life spans, 3) the need for focused studies among minority and migrant women, 4) an understanding of farm women and their leisure time, and 5) a broader application of the MBPS theory to include a large number of social variables shown to be associated with farm women and depressive symptoms that were not available in the dataset.