A Grounded Theory Approach to Navigating Infertility Care During U.S. Military Service

INTRODUCTION

In this study, we aimed to understand how active duty service members and their partners navigate the infertility care process within the Military Health System (MHS) while managing a military career.

MATERIALS AND METHODS

We obtained Institutional Review Board approval to employ a qualitative design using grounded theory methods. We recruited participants using purposive sampling, followed by theoretical sampling. We derived data from demographic questionnaires and semi-structured interviews. Consistent with grounded theory methods, we began analysis with line-by-line coding and moved to focused coding. We employed constant comparative analysis throughout the process to name, categorize, and conceptualize data and relationships.

RESULTS

The participants included 28 patients, five partners, nine health care providers, and two military leaders. The infertility care process began with active duty service members and their partners recognizing the desire to have a child and discovering infertility, followed by deciding to seek infertility care. The experience was temporally bound within the context of the military environment. We identified the following themes, which described facilitators and barriers to accessing care: Duty station location, career stage, military versus the civilian cost of services, command climate, and policy. These facilitators and barriers varied widely across the Department of Defense (DoD), which resulted in fragmented and inconsistent care cycles, contributed to emotional and physical stress, and created tension between career progression and family formation.

CONCLUSIONS

Understanding how military couples perceive and manage demands of infertility care may enhance access to care, decrease patient costs, improve outcomes, result in better support for military couples who experience infertility, and ultimately improve the health and military readiness of our armed forces. The results support the need for action by providers, policy makers, and military leaders to develop effective infertility treatment programs and policies in the DoD.

The Patient Care Experience as Perceived by Hispanic Patients With Chronic Illness Undergoing Transplant: A Grounded Theory

Hispanics are one of the largest-growing minorities, yet little is understood of the patient experience from their perspective. Patient experience is the current federally mandated hospital quality indicator that is measured via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Minority representation in the HCAHPS survey development however was not robust. This study used a constructivist grounded theory method to explore how English- and Spanish-speaking Hispanic patients seeking kidney and liver transplant care at a safety-net hospital perceive and interpret the care experience. A grounded theory process model emerged finding comfort, communication, connection, and care to be interdependent factors crucial for a positive hospital admission. Furthermore, "cultural context" was found to influence perception of each of these concepts. This research provides key insights into how Hispanics may perceive their needs when seeking care. A Supplemental Digital Content video abstract is available at http://links.lww.com/ANS/A50 .

Examining child flourishing, family resilience, and adversity in the 2016 National Survey of Children's Health

PURPOSE

Explore factors associated with flourishing and family resilience among children aged 6 months to 5 years old in the 2016 National Survey of Children's Health (NSCH).

DESIGN AND METHODS

Cross-sectional analysis of the 2016 NSCH was conducted using Kleinman and Norton's Regression Risk Analysis method to derive adjusted risk measures for logistic regression models to assess factors contributing to (1) child flourishing and (2) child flourishing stratified between resilient and non-resilient families.

RESULTS

In multivariable models, resilient families less often reported a child with two or more lifetime ACE exposures (ARD -0.11, 95% CI -0.15, -0.08), more likely to live in a supportive neighborhood (ARD 0.08, 95% CI 0.05,0.11), and more likely to report emotional support in raising children (ARD 0.07, 95% CI 0.12, 0.40). Accounting for ACE exposures, within resilient families, child flourishing was more likely when the child lived in a supportive neighborhood (ARD 0.09, 95% CI 0.03, 0.15), received care in a patient centered medical home (ARD 0.09, 95% CI 0.02,0.15), and when parents reported having emotional support in raising children (ARD 0.10, 95% CI 0.05, 0.17) Within non-resilient families, child flourishing was more likely when parents had emotional support in raising children (ARD 0.15, 95% CI 0.04,0.27).

CONCLUSION

Promoting emotional support for parents may bolster family resilience and help young children to flourish despite adversity.

PRACTICE IMPLICATIONS

Further research and innovative models of care are needed to optimize the role of pediatric primary care in promoting safe, stable, nurturing relationships and environments for children and families.

Examining the Relationship of Family Social Capital and Use of Pediatric Primary Health Care Services in the 2016-19 National Survey of Children's Health

INTRODUCTION

This study examined the relationship of family social capital (FSC) and pediatric primary health care services (PHCU) among young children aged 0-5 years in the United States. FSC involves the interrelated contexts of child health and family characteristics. Understanding how this impacts PHCU may reveal important considerations for supporting access and use of essential health care services.

METHOD

Using data from the 2016-19 National Survey of Children's Health (weighted N = 21,496,634), we conducted descriptive statistics and logistic regression to ascertain the relationship between FSC and PHCU.

RESULTS

Statistically significant contributions included FSC (odds ratio [OR] = 1.2; confidence interval [CI] = 1.08-1.40), high school (OR = 0.49; CI = 2.65-5.39), and some college (OR = 0.72; CI = 0.62-0.85) DISCUSSION: Findings support that FSC and parent academic achievement impact PHCU. Interventions that foster family connection and parent adult health literacy may enhance PHCU.

Achieving Access Parity for Inpatient Psychiatric Care Requires Repealing the Medicaid Institutions for Mental Disease Exclusion Rule

Approximately 3.4% of Americans have a mental health condition and suicide is the 10th leading cause of death. While the rate of mental health conditions has slightly increased for adult populations, America's youth has experienced a significant rise in depression. From 2008 to 2017, occurrence of depression in the adolescent population increased from 8.3% to 13.3%. As adolescents mature into adults; it is likely the rate of mental health conditions for the adult population will rise as well as it is the common thread that binds the diseases of despair: drug abuse, alcoholism, and suicide. Arising out of the deinstitutionalization movement of the 1960s, the Medicaid Institutions for Mental Disease (IMD) Exclusion Rule (§1905(a)(B) of the Social Security Act) prohibits reimbursement for Medicaid recipients ages 21 to 64 years receiving inpatient care at a psychiatric hospital with 16 or more beds. Consequently, the rule limits payment for psychiatric treatment to general hospitals and smaller, nonspecialized centers, which blocks patients from receiving inpatient care and transfers the financial burden of care onto psychiatric hospitals. The IMD Rule is approaching its 55th anniversary. It requires reevaluation. Although a state waiver process is available, use of this option has the potential to increase the incidence of racial and ethnic disparities across states. Full repeal of the IMD Exclusion Rule could help provide immediate access to inpatient care that is consistent nationwide and be a vital step toward creating financial, treatment and ethical parity for mental health services.

A Matter of Conscience: Examining the Law and Policy of Conscientious Objection in Health Care

Conscientious objection refers to refusal by a health care provider (HCP) to provide certain treatments, including the standard of care, to a patient based upon the provider's personal, ethical, or religious beliefs. Federal and state rules regarding conscientious objection have expanded the scope of legal protections that HCPs and institutions can invoke in support of refusal. Opponents of these rules argue that allowing refusal of care deprives patients of care that conforms to professionally established guidelines, contradicts long-standing principles related to informed consent, interferes with the ability of health care facilities to provide safe and efficient care, and leaves the patient without means of redress for injury. Proponents respond that such rules are necessary to preserve the moral integrity of providers, including institutions. Although refusal rules are most often associated with abortion, some HCPs have cited moral concerns regarding contraception, sterilization, prevention/treatment of sexually transmitted infections, transition-related care for transgender individuals, medication-assisted treatment of substance use disorders, the use of artificial reproductive technologies, and patient preferences for end-of-life care. Evidence suggests that the burden of conscientious refusal falls disproportionately on vulnerable populations, and legitimate concern exists that moral disagreement is merely pretext for discrimination. A careful balance must be struck between the defending the conscience rights of HCPs and the civil rights of patients.

Oxidative Stress Biomarker Decreased in Preterm Neonates Treated With Kangaroo Mother Care

OBJECTIVE

Due to physiological and metabolic immaturity, prematurely born infants are at increased risk because of maternal separation in many neonatal intensive care units (NICUs). The stress induced from maternal-infant separation can lead to well-documented short-term physiologic instability and potentially lifelong neurological, sociological, or psychological sequelae. Based on previous studies of kangaroo mother care (KMC) that demonstrated improvement in physiologic parameters, we examined the impact of KMC on physiologic measures of stress (abdominal temperature, heart rate, oxygen saturation, perfusion index, near-infrared spectrometry), oxidative stress, and energy utilization/conservation in preterm infants.

METHODS

In this randomized, stratified study of premature neonates, we compared the effects on urinary concentrations of biomarkers of energy utilization and oxidative stress of 1 hr of KMC versus incubator care on Day 3 of life in intervention-group babies (n = 26) and control-group babies (n = 25), respectively. On Day 4, both groups received 1 hr of KMC. Urinary samples were collected 3 hr before and 3 hr after intervention/incubator care on both days. Energy utilization was assessed by measures of adenosine triphosphate (ATP) degradation (i.e., hypoxanthine, xanthine, and uric acid). Oxidative stress was assessed using urinary allantoin. Mixed-models analysis was used to assess differences in purine/allantoin.

RESULTS

Mean allantoin levels over Days 3 and 4 were significantly lower in the KMC group than in the control group (p = .026).

CONCLUSIONS

Results provide preliminary evidence that KMC reduces neonatal oxidative stress processes and that urinary allantoin could serve as an effective noninvasive marker for future studies.

The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers

OBJECTIVE

We explored relationships between maternal health literacy (HL), communicative self-efficacy (SE), social support (SS) and maternal perception of interactions with health care providers (HCPs).

METHODS

Using a cross-sectional, correlational design, we assessed sociodemographic characteristics, maternal HL, social support, communicative self-efficacy, and interpersonal interactions with HCPs among 124 low-income Latina mothers of young children.

RESULTS

Informal SS significantly predicted maternal SE in interactions. SE predicted maternal perception of a HCP's ability to "elicit and respond to her concerns."

DISCUSSION

Interventions to improve maternal self-efficacy in interacting with HCPs among low health literate Latina mothers may positively impact pediatric health outcomes.

Children's health care and the Patient Protection and Affordable Care Act: what's at stake?

Although the Patient Protection and Affordable Care Act (hereafter referred to as the ACA) of 2010 does not explicitly target the health care needs of children, its significant reforms and cascading effects throughout our complex health system are likely to directly and indirectly affect children’s health care. The ACA increases insurance coverage for children and their families by covering comprehensive preventive services with no cost sharing, eliminating exclusions for preexisting conditions, prohibiting lifetime dollar limits, extending dependent health benefits to 26 years of age, and expanding coverage to many previously uninsured parents. Despite these advances, some provisions of the ACA have the potential to compromise children’s health care in unanticipated ways. Because children account for a disproportionately small percentage of overall health care spending, the effect of the ACA on children is not on the radar of those individuals implementing the ACA who are more focused on insurance expansion and cost control among adults. Thus, it falls to children’s health advocates to monitor the ACA’s effect on child health care, to both minimize harm and maximize opportunities for improvement.

Health literacy and interpersonal interactions as predictors of maternal perception of ambulatory care for low-income, Latino children

OBJECTIVE

This study explores whether maternal HL (MHL) and maternal perception of health care provider (HCP) interpersonal interactions predict maternal perception of quality of pediatric ambulatory care received.

METHODS

This cross-sectional study included 124 low-income Latina mothers of children 3 months to 4 years. Maternal HL, perception of maternal-HCP interpersonal interactions, and perception of pediatric ambulatory care were measured using well-validated surveys.

RESULTS

In adjusted hierarchical regression models, HCP fail to speak clearly (β=-.225, 95% CI -13.998, -1.960, p=.01) and explain results (β=.344, 95% CI 3.480, 13.010, p=.001) predicted perception of quality of developmental guidance received. Explaining results (β=.422, 95% CI 5.700, 14.089, p=<.001), working out treatment together (β=.441, 95% CI 6.657, 13.624, p<.001) and MHL (β=-.301, 95% CI -7.161, -2.263, p<.001) predicted perception of family centeredness of care.

CONCLUSIONS

Speaking with clarity, explaining results fully and working with the mother to determine a child's plan of care is most predictive of whether she feels her child is receiving high quality pediatric ambulatory care services.

PRACTICE IMPLICATIONS

Interventions that target mother and provider interaction may improve perception of care.

Knowledge and perceptions of health literacy among nursing professionals

Low health literacy affects nearly half of the U.S. population. Health care professionals may not recognize low health literacy in their patients nor understand its impact on health outcomes. The purpose of this pilot study was to describe nurses' knowledge and perceptions of low health literacy on patients, their practice, and the health system. This cross-sectional, descriptive study used a web-based survey to assess the knowledge and perceptions of health literacy among nursing professionals. Registered nurses licensed by the State of California were randomly selected and invited to participate in the study. Data analysis included descriptive statistics to describe nursing professionals' general knowledge and perceptions. Qualitative textual analysis was done on participant responses to a survey question that asks participants to define health literacy using their own words. Results of this study revealed that nursing professionals' knowledge of health literacy and their understanding on the role health literacy plays on patient health outcomes is limited. Health literacy was also reported to be a low priority among providers and organizations. Nursing plays an important role in direct patient care and in the delivery of health services. Educating nurses on health literacy and improving patient communication and understanding can improve health outcomes.

Community violence: its impact on the development of children and implications for nursing practice

An alarming increase in the prevalence of violent crime in the United States has lead to the birth of a new subset of victims, children who witness acts of violence. Results of multiple studies suggest that chronic exposure to violence has a profound negative impact on children's cognitive, social, psychologic, and moral development. As primary care providers, pediatric nurses and nurse practitioners are well-positioned to assess these children for early signs of exposure to violence, offer guidance and counseling, and make referrals for proper treatment.