Factors Associated with Planned Future Use of PrEP in the Next 3 Months and Likelihood to Use PrEP Among Black Cisgender HIV-negative Women in Texas

Identifying and then addressing barriers and leveraging facilitators is important to help increase pre-exposure prophylaxis (PrEP) use among Black women vulnerable to HIV acquisition. The present cross-sectional study examined what factors were associated with future plans to use PrEP, and general likelihood to use it among a convenience sample of 152 adult, Black cisgender women from three metropolitan areas in Texas. The final multivariable logistic regression model revealed that relationship status (aOR = 0.20, 95% CI: 0.05-0.73, p < 0.05), PrEP anticipated stigma (aOR = 0.29, 95% CI: 0.10-0.78, p < 0.05), perceived discrimination (aOR = 0.40, 95% CI: 0.21-0.78, p < 0.01) and interest in learning more about PrEP (aOR = 5.32, 95% CI: 2.60-10.9, p < 0.001) were associated with future plans to use PrEP. The final multivariable linear regression model with maximum likelihood estimation identified that perceived discrimination (β=-0.24, SE: -0.38 - -0.10, p < 0.01), perceived HIV risk (β = 0.33, SE: 0.18-0.49, p < 0.001), willingness to use PrEP with condoms (β = 1.26, SE: 0.94-1.60, p < 0.001), and comfort communicating about PrEP with a provider (β = 0.23, SE: 0.06-0.41, p < 0.01) were associated with general likelihood to use PrEP. Findings reveal key factors that warrant further attention and examination toward improving PrEP use within this population.

Community-based participatory research to guide adoption of culturally responsive trauma-informed HIV care throughout Nashville, Tennessee

Background

Psychological trauma is a highly prevalent driver of poor health among people with HIV (PWH) in the Southern United States (U.S.). Trauma-informed care (TIC) has potential to advance national Ending the HIV Epidemic (EHE) goals, but formative research is needed to tailor TIC implementation to complex and interdependent HIV networks. Methods: We applied a community-based participatory research (CBPR) approach to iteratively engage personnel from high volume HIV care institutions in Nashville, Tennessee. Current practices and potential implementation determinants were identified through participatory process mapping (PM) and key informant interviews. The Consolidated Framework for Implementation Research (CFIR) was applied to deductively code interview data. Personnel attending a dissemination summit developed a network-wide implementation plan.

Results

Data were collected with personnel from five institutions (e.g., community-based organizations, primary care clinics, public health department), for PM (n=48), interviews (n=35), and the summit (n=17). Results suggest there are limited trauma screenings, assessments, and services across the network. Relevant Characteristics of Individuals included a trauma-sensitive workforce committed to continuous learning and TIC adoption. Relevant Inner Setting Factors were networks and communications, with strong tension for change, high compatibility with TIC, and need for advancing cultural responsiveness. Relevant Outer Setting Factors included patient needs and resources and cosmopolitanism, with need for better leveraged mental health services. Relevant Process domains were champions and leadership, with need to diversify championship among leaders. Relevant Intervention Characteristics included relative advantage and complexity, with need for personnel wellness initiatives and increased engagement with the community as service designers. Four recommendations included development of shared communication systems, personnel wellness campaigns, routine evaluations to inform practices, and culturally responsive care initiatives.

Conclusion

Modifiable TIC determinants were identified, and a community-created implementation plan was developed to guide adoption. Future research will focus on city-wide implementation and strengthening pre-implementation research in other settings.

Optimizing an Outpatient mHealth Intervention for Children with Burns: A Convergent Mixed-Methods Study

Burn injury is one of the most common traumatic injuries in childhood. Fortunately, 90% of pediatric burns may be treated in the outpatient setting after appropriate burn triage. Patients with burns face significant geographic disparities in accessing expert burn care due to regionalized care. To aid patients and their families during acute outpatient burn recovery, we developed a smartphone app, Telemedicine Optimized Burn Intervention (TOBI). With this app, we aimed to increase access to care by allowing secure, streamlined communication between patients and burn providers, including messaging and wound image transfer. The purpose of this study was to systematically evaluate user feedback to optimize the patient and provider experience. TOBI was evaluated using a convergent mixed-methods approach consisting of qualitative semi-structured interviews and quantitative measurements of app usability via the mHealth App Usability Questionnaire. Participants included 15 caregivers of pediatric patients with burns who used TOBI during treatment and ten burn providers. Users found TOBI to be a highly usable application in terms of usefulness, ease of use, satisfaction, and functionality. Qualitative data provided insight into user experience, satisfaction and preferences, difficulty navigating, usability and acceptability, and potential improvements. Although most users were highly satisfied, improvements were needed to optimize the burn app. We systematically made these improvements before we released TOBI for routine patient use. This study uncovered helpful recommendations for app improvements that can be generalized to other mobile health apps to increase their appeal and adoption.

A qualitative metasynthesis of stigma in women living with HIV in the United States

Our goal was to synthesize qualitative studies on HIV-related stigma as experienced by women living with HIV (WLWH) in the U.S. Qualitative metasynthesis techniques as developed by Sandelowski et al. (Res Nurs Health 30(1):99-111, 2007) were used to integrate and update findings on stigma in WLWH in the U.S. in 43 reports of qualitative studies conducted between 2004 and 2023 with 1118 participants. Developed themes explored a collective narrative of women first surviving the intersectionality of multiple sources of stigma, discovering non-linear pathways to transcend their stigma, and finally experiencing resilience through their transcendence of stigma. While this metasynthesis revealed similarities to an earlier metasynthesis in the ubiquity and persistence of stigma, they differ primarily in women's abilities to find agency in managing and opposing their stigma. This cognitive reframing of their stigma helped women to redefine stigma as ignorance and move towards a more positive assessment of the self. In doing so, they separated themselves from their stigma and the damaging effects of it. Findings from this metasynthesis may serve as a useful tool for the development of stigma reduction interventions specific to the needs and experiences of WLWH in the U.S.

A Systematic Review of Self-Management Interventions Conducted Across Global Settings for Depressive Symptoms in Persons with HIV

Depressive symptoms can affect health outcomes in people living with HIV (PLWH) including adherence to treatment and disease prognosis. Self-management interventions targeting depressive symptoms have been effective in preventing these negative sequelae of depressive symptoms. The processes of self-management include learning skills related to living with the illness needs, accessing resources to manage the illness, and coping with the illness. A systematic literature review was conducted to appraise and synthesize the current evidence of self-management interventions targeting depressive symptoms in PLWH. Following the PRISMA guidelines, an electronic search of 4 databases was conducted. Original studies written in English that used a randomized controlled trial design to test the effect of self-management intervention on depressive symptoms were included. Studies were selected that were published on/before April 19, 2022, thus yielding 13 relevant articles. Risk of bias was assessed using the NIH Quality Assessment Tool for Controlled Intervention Studies and narrative synthesis was used to synthesize the results. 40 to 755 participants were included in the studies, with each using various measures to assess depressive symptoms pre-and post-intervention, and timepoints for assessing depressive symptoms post-intervention varied. While 12 studies showed a significant reduction in depressive symptoms post-intervention, only 4 studies that used individual coaching or technology showed lower depressive symptoms in intervention groups in comparison to the control groups. This review can be used to inform scale-up and dissemination of these interventions to improve depressive symptoms in PLWH.

Critical Care Nurses' Experiences of Caring for Patients With COVID-19: Results of a Thematic Analysis

BACKGROUND

The COVID-19 pandemic has challenged health care professionals, especially those working in intensive care units (ICUs).

OBJECTIVES

To explore critical care nurses' experiences with and perceptions of the COVID-19 pandemic during the early phases of the pandemic.

METHODS

Data were from national surveys conducted during March and April 2020 to assess ICU providers' perceptions of the initial phases of the pandemic. A total of 831 responses from nurses to open-ended questions were examined by using thematic analysis. The questions assessed potentially limited resources in the ICU, adequacy of staffing, and measures used to reduce the possibility of spreading COVID-19 to family members.

RESULTS

Overarching themes concerned access to equipment and preventive measures taken to reduce exposure to the virus. These themes included "sheltering the patient when I don't have enough" and "protecting those I love when I am a vector of transmission." Subthemes for the first overarching theme included not having enough personal protective equipment, not enough staff and not enough properly trained staff, and not enough institutional support. Subthemes for the second overarching theme included "isolating myself from everyone I care about" and "isolating everything I touch from everyone I care about."

CONCLUSIONS

This thematic analysis identified several concerns of ICU nurses related to caring for patients in the initial phases of the COVID-19 pandemic. Ensuring adequate supplies, staffing, and administrative and emotional support are provided to frontline health care providers during the ongoing pandemic remains essential.

Results of a National Survey: Ongoing Barriers to APRN Practice in the United States

Limited information is available on the barriers to practice for advanced practice registered nurses (APRNs) among states with full, restricted, and reduced practice. The purpose of this study is to identify practice barriers in relationship to United States (U.S.) state practice authority, APRN type, area of practice (rural, suburban, urban), and nature of practice (outpatient, inpatient, and both). An electronic survey of a convenience sample of APRNs was conducted to assess barriers to practice. Identified barriers were examined based on state practice environment, APRN role, practice setting, and location. Data were analyzed using thematic analysis for qualitative data and descriptive analysis for quantitative data. Over 7,000 APRNs representing all 50 states participated. Themes that were identified and reported by respondents, included licensure and administrative barriers, therapy restrictions, physician signature requirements, a lack of collegiality, prescribing barriers, uneven reimbursement, physician only procedures, and telehealth issues. Barriers were identified in all states, regardless of the type of practice authority. All four APRN role types identified practice barriers, some of which were more frequent for some roles than others. Restrictions for home health approval and the requirement for a physician signature for durable medical supply orders were identified by over 40% of respondents practicing in rural areas. Barriers to APRN practice continue to restrict aspects of patient care and patient access to care, even in states with full practice authority. Continued efforts to reduce barriers to APRN practice are needed to ensure patient access to care, especially in rural areas.

Perspectives on Aging and End of Life Among Lower Socioeconomic Status (SES) Older Adults

Objective: To explore the experiences of aging that influence perceptions of and receptivity to planning for aging and EOL among lower SES older adults. Methods: Supported by a frailty-focused communication educational aid, semi-structured interviews were conducted with 20 older adults residing in income-assisted housing. Follow-up interviews were conducted 2 weeks later. Descriptive content analysis was performed. Results: Participants mean age was 62.4, and 75% were African American. Six categories emerged to create a narrative of lower SES older adults' experiences, including (1) readiness to plan for aging and EOL, (2) interaction with the healthcare system, (3) daily life with insufficient resources, (4) the role of religiosity, (5) relationships with others, and (6) motivation and health status. Discussion: Life course vulnerabilities and struggles of lower SES older adults preclude opportunities to proactively plan for aging and EOL. Holistic interventions and innovative approaches are needed to address aging across the life course.

A Critical Review of Symptom Management Nursing Science on HIV-Related Fatigue and Sleep Disturbance

Despite improved antiretroviral treatments, people living with HIV (PLWH) continue to suffer from HIV-related fatigue and sleep disturbances. We first reviewed the definition, etiology, and research breakthroughs of HIV-related fatigue and sleep disturbances, then analyzed nurse-led symptom management studies to describe their efficacy and make recommendations for future symptom research. We searched PubMed, CINAHL, PsycInfo, Psych and Behavioral Sciences Collection, and Scopus to identify nurse-led studies on symptom management for PLWH in the past 20 years. A total of 13 experimental or quasi-experimental studies were identified. The types of interventions included exercise, cognitive behavioral therapy, coaching, and symptom management manualized self-care activities. Currently, we cannot recommend with certainty any of the tested symptom management strategies to reduce fatigue or sleep disturbances. The current findings need to be confirmed and expanded to understand optimal dosing and sustainability.

The Experiences of Parent Dyads in the Neonatal Intensive Care Unit: A Qualitative Description

Background The hospitalization of an infant in the neonatal intensive care unit (NICU) is a distressing and often unexpected event for parents. Parents have risk for depression, anxiety, and posttraumatic stress, which can adversely impact them and their relationship. The hospitalization and subsequent stress may affect parents' capability to connect with and parent their child. Purpose Describe parents' experiences and ability to cope with the NICU; identify experiential and coping differences between mothers and fathers; examine the effect of the NICU hospitalization on the parent dyad relationship. Methods A qualitative descriptive design with dyadic interviews examined parents' experiences and coping skills, and subsequent effects on the parental relationship. Data collection continued until saturation was achieved and no new themes emerged. Through content analysis, an accurate description of parents' experiences in the NICU was rendered. Findings Nine themes from eight dyad interviews emerged and were categorized within the six domains of the transactional theory of stress and coping. The major themes were: Deeply Distressing, Unexpected and Unprepared, Expecting to Hear and Be Heard, Becoming Parents, Stronger Together, Support is Key, Parents Want Better Communication, and Adjusting to the NICU. Implications for practice Support from professionals and family, and clear and consistent communication from the treatment team helped alleviate parents' anxiety about their infant. Implications for research Research regarding the impact of a NICU hospitalization on the relationship between parent dyad members, specifically longitudinal studies, may lead to a better understanding of the long-term effects of this specific stressor on parents.

Paving the way for application of next generation risk assessment to safety decision-making for cosmetic ingredients

Next generation risk assessment (NGRA) is an exposure-led, hypothesis-driven approach that has the potential to support animal-free safety decision-making. However, significant effort is needed to develop and test the in vitro and in silico (computational) approaches that underpin NGRA to enable confident application in a regulatory context. A workshop was held in Montreal in 2019 to discuss where effort needs to be focussed and to agree on the steps needed to ensure safety decisions made on cosmetic ingredients are robust and protective. Workshop participants explored whether NGRA for cosmetic ingredients can be protective of human health, and reviewed examples of NGRA for cosmetic ingredients. From the limited examples available, it is clear that NGRA is still in its infancy, and further case studies are needed to determine whether safety decisions are sufficiently protective and not overly conservative. Seven areas were identified to help progress application of NGRA, including further investments in case studies that elaborate on scenarios frequently encountered by industry and regulators, including those where a ‘high risk’ conclusion would be expected. These will provide confidence that the tools and approaches can reliably discern differing levels of risk. Furthermore, frameworks to guide performance and reporting should be developed.

"Since I'm a little bit more mature": contraception and the arc of time for women in midlife

Background

Contraceptive methods have rapidly evolved over the past several decades, but little research has explored how women interact with contraception over time. Exploring contraceptive beliefs, perceptions, and attitudes of women in midlife can reveal much about how lived experience affects contraceptive decisions and reproductive health choices.

Methods

Individual, semi-structured interviews were conducted with 20 women between the ages of 40 and 55 who had not reached menopause and did not have a permanent method of sterilization. Data were coded using qualitative descriptive methods.

Results

Three major themes were identified: 1) journey toward empowerment; 2) finding the right fit: evolution over time; and 3) anticipating a transition. Past experiences with or fear of side effects and hormones were common reasons to change or avoid certain contraceptive methods. Most participants were happy with their contraceptive method; however, those who were unhappy were more likely to vocalize fatigue at continuing to need contraception as menopause approached.

Conclusion

Approaching contraceptive counseling from a place that considers the journey with contraception over a reproductive life span will help identify how beliefs, perceptions, and attitudes of women affect their contraceptive practices and choices.

The Reproductive Health Priorities, Concerns, and Needs of Women in Midlife: A Feminist Poststructuralist Qualitative Analysis

Reproductive health research rarely involves the inclusion of women over 40, creating a large knowledge gap regarding women in midlife. Women continue to have reproductive health needs, concerns, and priorities up to the point of menopause that should be examined to improve reproductive health outcomes and provide individualized care. In-depth, individual, semi-structured interviews were conducted with 20 women between the ages of 40 and 55 who had not reached menopause and did not have a permanent method of sterilization. Using the feminist poststructuralist tenets, three major themes were identified: (a) knowledge acquisition during the perimenopause, (b) subjectivity regarding family planning, and (c) the agency of aging. Participants spoke to a need for reproductive health that listens to their lived experience, addresses menopause clinically and positively, and encourages autonomously driven health priorities. Further research on effective nonhormonal contraception, education on perimenopausal symptoms, and healthy aging is necessary.

A Communication Model to Bridge Adolescent Patients, Caregivers, and Physicians in Transitions of Care

A transition of care (TOC) process from pediatric to adult medicine ensures that adolescents receive ongoing care into young adulthood, a time of high risk for preventable morbidity and mortality. We explored patient, caregiver, and physician perspectives on ways to improve TOC communication with healthy adolescents. Two researchers conducted key informant interviews with healthy 12- to 18-year-old adolescents, their caregivers, and primary care physicians working in pediatric, internal, and family medicine. Data saturation was reached after interviewing 12 adolescents, 10 caregivers, and 36 physicians. Three themes were identified: perceptions of TOC; effective communication among the triad of adolescents, caregivers, and providers; and early communication about TOC preparation. From these themes, a model of communication was identified and adapted, outlining the communication skills and responsibilities for physicians and patients during TOC. Physicians must understand how to use strong, consistent, adolescent-centered communication to execute effective TOC.

A Feasibility Study to Develop and Test a Cognitive Behavioral Stress Management Mobile Health Application for HIV-Related Fatigue

CONTEXT

Exacerbated by life stressors, fatigue is the most common symptom for people living with HIV.

OBJECTIVE

To adapt, develop, and assess the feasibility of a Cognitive Behavioral Stress Management Mobile Health (CBSM mHealth) application (app) for HIV-related fatigue.

METHODS

This study had two phases: app development with key informants (N = 5) and a randomized controlled trial (N = 30). Patients randomized to the intervention group completed 10 weekly CBSM modules; those in the control group received a generic healthy lifestyle app. Measures included HIV-related fatigue, depression, anxiety, stressful life events, CD4 count, HIV viral load, credibility and acceptability of the intervention, and barriers to treatment participation.

RESULTS

We were able to recruit participants for this study, and they were able to complete the required measures. They found the intervention to be credible and acceptable and reported few barriers to treatment participation. The direction of change in the primary outcome, a decrease in fatigue, is in the expected direction and provides evidence of the promise of the intervention, which still needs to be tested in an adequately powered trial. For completers (randomized to the intervention group and completed at least 80% of the modules), there were significant changes (95% CI; lower scores indicate improvement) in fatigue intensity (from 64.2 to 59.7) and overall fatigue-related functioning (from 6.6 to 4.2).

CONCLUSION

We have proof of concept as to the feasibility, acceptability, and initial signals of efficacy for an mHealth intervention to help people with HIV-related fatigue better cope with stress and reduce their fatigue.

Women's Contraceptive Perceptions, Beliefs, and Attitudes: An Integrative Review of Qualitative Research

INTRODUCTION

Unintended pregnancy rates will remain high until researchers explore the lived experience of women's relationships with contraception. This integrative review examines the extant qualitative literature on women's contraception to illuminate common themes in women's perspectives through the lens of the feminist poststructuralist framework.

METHODS

A literature review of PubMed and CINAHL databases was completed for English-language studies conducted in the United States from January 2008 through September 2018 that qualitatively examined women's perceptions, beliefs, and attitudes regarding contraception. Reports, dissertations, mixed-methods research, and literature reviews were excluded. The sample, methods, and findings of 19 studies were reviewed. Themes were identified using the 5 major tenets of the feminist poststructuralist framework: discourse, power, language, subjectivity, and agency.

RESULTS

Themes of power imbalance between partners and health care providers; societal and communal discourses on femininity and motherhood; distrust of hormonal contraception; the ability to enhance personal agency through contraceptive decision making; and a need for open, patient-focused communication arose from the 19 studies included in the review.

DISCUSSION

Using a feminist poststructuralist framework to examine women's contraceptive perceptions illuminates and magnifies the many ways in which contraceptive beliefs and use are dependent on gender roles and power dynamics. Gaps in knowledge specific to older women and exploration of women's subjectivity should be addressed. Clinicians should evaluate the power structures inherent to their practice while providing woman-focused, evidence-based contraceptive education.

From Qualitative Meta-Summary to Qualitative Meta-Synthesis: Introducing a New Situation-Specific Theory of Barriers and Facilitators for Self-Care in Patients With Heart Failure

Situation-specific theories provide nurses with a vehicle to interpret situations, guide their decisions or make assumptions about factors influencing a health problem. In this article, we used meta-synthesis techniques to integrate statements of findings pertaining to barriers and facilitators to heart failure self-care that were derived previously through meta-summary techniques leading to a new situation-specific theory. According to our proposed theory, self-care behavior is the result of a patient's naturalistic decision-making process. This process is influenced by two key concepts: "self-efficacy" and the "patient's disease concept of heart failure." Numerous facilitative and inhibitive factors have been identified influencing these two key concepts as well as the decision-making process, thereby either enabling or hampering the execution of effective heart failure self-care. Further research is needed to validate the model through empirical testing. Once fully matured, the model may be useful in developing behavioral interventions aiming at enhancing adherence to self-care recommendations.

Obtaining waivers of parental consent: A strategy endorsed by gay, bisexual, and queer adolescent males for health prevention research

BACKGROUND

Requiring parental consent in studies with sexual minority youth (SMY) can sometimes be problematic as participants may have yet to disclose their sexual orientation, may not feel comfortable asking parents' permission, and may promote a self-selection bias.

PURPOSE

We discuss rationale for waiving parental consent, strategies to secure waivers from review boards, and present participants' feedback on research without parents' permission.

METHODS

We share our institutional review board proposal in which we made a case that excluding SMY from research violates ethical research principles, does not recognize their autonomy, and limits collection of sexuality data.

DISCUSSION

Standard consent policies may inadvertently exclude youth who are at high risk for negative health outcomes or may potentially put them at risk because of forced disclosure of sexual orientation. Securing a waiver addresses these concerns and allows for rich data, which is critical for providers to have a deeper understanding of their unique sexual health needs.

CONCLUSION

To properly safeguard and encourage research informed by SMY, parental consent waivers may be necessary.

Black Mothers Living With HIV Picture the Social Determinants of Health

The purpose of our study was to explore the social determinants of health for Black mothers living with HIV in the southeastern region of the United States. In this exploratory study, we used qualitative methods of in-depth interviewing and photo elicitation at three time points to provide a comprehensive examination of the meaning that the constructs held for participants (n = 18). The social determinants of health, identified primarily as positive health determinants by the participants, included social support, religion, animal companions, and the physical environment. The social determinants of health identified as mixed determinants, having both positive and negative qualities, were transportation and housing. Each of these social determinants is presented with definitions and exemplars. Additionally, aspects of each determinant of health that may be meaningfully addressed through process and structural level interventions are explored.

Standardisation of defined approaches for skin sensitisation testing to support regulatory use and international adoption: position of the International Cooperation on Alternative Test Methods

Skin sensitisation is the regulatory endpoint that has been at the centre of concerted efforts to replace animal testing in recent years, as demonstrated by the Organisation for Economic Co-operation and Development (OECD) adoption of five non-animal methods addressing mechanisms under the first three key events of the skin sensitisation adverse outcome pathway. Nevertheless, the currently adopted methods, when used in isolation, are not sufficient to fulfil regulatory requirements on the skin sensitisation potential and potency of chemicals comparable to that provided by the regulatory animal tests. For this reason, a number of defined approaches integrating data from these methods with other relevant information have been proposed and documented by the OECD. With the aim to further enhance regulatory consideration and adoption of defined approaches, the European Union Reference Laboratory for Alternatives to Animal testing in collaboration with the International Cooperation on Alternative Test Methods hosted, on 4-5 October 2016, a workshop on the international regulatory applicability and acceptance of alternative non-animal approaches, i.e., defined approaches, to skin sensitisation assessment of chemicals used in a variety of sectors. The workshop convened representatives from more than 20 regulatory authorities from the European Union, United States, Canada, Japan, South Korea, Brazil and China. There was a general consensus among the workshop participants that to maximise global regulatory acceptance of data generated with defined approaches, international harmonisation and standardisation are needed. Potential assessment criteria were defined for a systematic evaluation of existing defined approaches that would facilitate their translation into international standards, e.g., into a performance-based Test Guideline. Informed by the discussions at the workshop, the ICATM members propose practical ways to further promote the regulatory use and facilitate adoption of defined approaches for skin sensitisation assessments.

Cobalt oxide as a selective co-catalyst for water oxidation in the presence of an organic dye

In photobiocatalytical processes involving the simultaneous oxidation of water and reduction of specific organic molecules (e.g., cofactors), the lack of physical separation of the redox half-reactions adversely affects the product stability. This is largely because organic molecules are generally less stable within harsh oxidative environments. In general, surface co-catalysts are able to improve the selectivity of photocatalysts towards water oxidation. However, harsh oxidative environments reduce the chemical stability of the organic molecules. Herein, we show that the use of Co₃O₄ as a surface co-catalyst on silver orthophosphate improve water photo-oxidation in the presence of organic dye molecules, such as methylene blue, that typically exhibits susceptibility toward photodegradation. The presence of Co₃O₄ on the photocatalyst surface prevents the adsorption of the organic dye, thus reducing its degradation rate. These findings provide a promising scenario for the visible light-driven reduction of organic molecules using water as an electron donor.

[Elevated incidence of cognitive impairment in patients with asymptomatic carotid stenosis]

INTRODUCTION

Stroke is one of the main causes of mortality and functional disability in developed countries. Carotid stenosis (CS) is considered the reason for 20-30% of strokes. However, the studies that have gone into depth on the cognitive status of these patients are limited.

AIM

To investigate the cognitive performance of CS patients and its relationship with clinical variables (carotid obstruction, lifestyle).

PATIENTS AND METHODS

33 CS patients were evaluated using a broad neuropsychological protocol, and were divided into two groups: symptomatic CS and asymptomatic CS.

RESULTS

50-57% of CS patients showed deficits in processing speed and visual memory (immediate recall). 41.9% showed altered performance in semantic fluency, whereas the percentage was 30% in digits subtest. The percentage of altered performance was 20-27% in verbal memory (learning curve, delayed recall) and visual memory (delayed recall). No significant differences were found between the symptomatic CS and asymptomatic CS groups. Cognitive performance correlated significantly with lifestyle scale factors, but not with the percentage of carotid obstruction.

CONCLUSION

A high percentage of CS patients showed a clinically altered performance in different cognitive domains, regardless of suffering vascular neurological symptoms (symptomatic vs asymptomatic CS). A close relationship was found between lifestyle and cognitive status of CS patients.

A qualitative meta-summary using Sandelowski and Barroso’s method for integrating qualitative research to explore barriers and facilitators to self-care in heart failure patients

Background:

Individual qualitative studies provide varied reasons for why heart failure patients do not engage in self-care, yet articles that aggregated primary studies on the subject have methodological weaknesses that justified the execution of a qualitative meta-summary.

Aim:

The aim of this study is to integrate the findings of qualitative studies pertaining to barriers and facilitators to self-care using meta-summary techniques.

Methods:

Qualitative meta-summary techniques by Sandelowski and Barroso were used to combine the findings of qualitative studies. Meta-summary techniques include: (1) extraction of relevant statements of findings from each report; (2) reduction of these statements into abstracted findings and (3) calculation of effect sizes. Databases were searched systematically for qualitative studies published between January 2010 and July 2015. Out of 2264 papers identified, 31 reports based on the accounts of 814 patients were included in the meta-summary.

Results:

A total of 37 statements of findings provided a comprehensive inventory of findings across all reports. Out of these statements of findings, 21 were classified as barriers, 13 as facilitators and three were classed as both barriers and facilitators. The main themes relating to barriers and facilitators to self-care were: beliefs, benefits of self-care, comorbidities, financial constraints, symptom recognition, ethnic background, inconsistent self-care, insufficient information, positive and negative emotions, organizational context, past experiences, physical environment, self-initiative, self-care adverse effects, social context and personal preferences.

Conclusion:

Based on the meta-findings identified in this study, future intervention development could address these barriers and facilitators in order to further enhance self-care abilities in heart failure patients.

21st Century Parent-Child Sex Communication in the United States: A Process Review

Parent-child sex communication results in the transmission of family expectations, societal values, and role modeling of sexual health risk-reduction strategies. Parent-child sex communication's potential to curb negative sexual health outcomes has sustained a multidisciplinary effort to better understand the process and its impact on the development of healthy sexual attitudes and behaviors among adolescents. This review advances what is known about the process of sex communication in the United States by reviewing studies published from 2003 to 2015. We used the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, SocINDEX, and PubMed, and the key terms "parent child" AND "sex education" for the initial query; we included 116 original articles for analysis. Our review underscores long-established factors that prevent parents from effectively broaching and sustaining talks about sex with their children and has also identified emerging concerns unique to today's parenting landscape. Parental factors salient to sex communication are established long before individuals become parents and are acted upon by influences beyond the home. Child-focused communication factors likewise describe a maturing audience that is far from captive. The identification of both enduring and emerging factors that affect how sex communication occurs will inform subsequent work that will result in more positive sexual health outcomes for adolescents.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.

Pattern of neuropsychological impairment in the early phase of relapsing-remitting multiple sclerosis

To investigate the neuropsychological profile in the first few years post-onset of relapsing-remitting multiple sclerosis (MS) we carried out a comprehensive neuropsychological evaluation of 33 patients characterized by very short evolution of this disease, minimal levels of neurological disability and preserved general cognition. Thirty-three individually pair-matched controls were also evaluated. Patients performed as well as controls on many of the cognitive exploration measures. Nevertheless, the group of patients evinced a general slowness that affected motor execution and cognitive processing. Memory functions were characterized by preservation of working memory, retrieval or storage of information and a deficit at the acquisition phase in (verbal and visual) supraspan tasks. In addition, significant correlations were observed between some measures of information processing speed and memory. These results highlight the importance of studying cognitive deficits not only in the different subtypes of MS but also in different phases of the disease.

Transitional care in skilled nursing facilities: a multiple case study

BACKGROUND

Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.

METHODS

In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.

RESULTS

Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.

CONCLUSIONS

Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

The development and psychometric analysis of the Chinese HIV-Related Fatigue Scale

AIMS AND OBJECTIVES

To develop a Chinese version of the human immunodeficiency virus-related Fatigue Scale and examine its reliability and validity.

BACKGROUND

Fatigue is found in more than 70% of people infected with human immunodeficiency virus. However, a scale to assess fatigue in human immunodeficiency virus-positive people has not yet been developed for use in Chinese-speaking countries.

DESIGN

A methodologic study involving instrument development and psychometric evaluation was used.

METHODS

The human immunodeficiency virus-related Fatigue Scale was examined through a two-step procedure: (1) translation and back translation and (2) psychometric analysis. A sample of 142 human immunodeficiency virus-positive patients was recruited from the Infectious Disease Outpatient Clinic in central Taiwan. Their fatigue data were analysed with Cronbach's α for internal consistency. Two weeks later, the data of a random sample of 28 patients from the original 142 were analysed for test-retest reliability. The correlation between the World Health Organization Quality of Life Assessment-Human Immunodeficiency Virus and the Chinese version of the human immunodeficiency virus-related Fatigue Scale was analysed for concurrent validity. The Chinese version of the human immunodeficiency virus-related Fatigue Scale scores of human immunodeficiency virus-positive patients with highly active antiretroviral therapy and those without were compared to demonstrate construct validity.

RESULTS

The internal consistency and test-retest reliability of the Chinese version of the human immunodeficiency virus-related Fatigue Scale were 0·97 and 0·686, respectively. In regard to concurrent validity, a negative correlation was found between the scores of the Chinese version of the human immunodeficiency virus-related Fatigue Scale and the World Health Organization Quality of Life Assessment-Human Immunodeficiency Virus. Additionally, the Chinese version of the human immunodeficiency virus-related Fatigue Scale could be used to effectively distinguish fatigue differences between the human immunodeficiency virus-positive patients with highly active antiretroviral therapy and those without.

CONCLUSIONS

The Chinese version of the human immunodeficiency virus-related Fatigue Scale presents good reliability and validity through a robust psychometric analysis. This scale can be appropriately applied to human immunodeficiency virus-positive patients by clinical staff and case managers in Chinese-speaking countries.

RELEVANCE TO CLINICAL PRACTICE

The Chinese version of the human immunodeficiency virus-related Fatigue Scale is an effective and comprehensive tool that can help clinical professionals measure the frequency, strength and impact on the quality of life of fatigue in Chinese human immunodeficiency virus-positive patients.

Facilitators and Barriers to HIV Screening: A Qualitative Meta-Synthesis

Accomplishments in biomedical research and technology, combined with innovative community and clinically based interventions, have expanded HIV testing globally. However, HIV screening and receipt of results remains a challenge in some areas. To optimize the benefits of HIV screening, it is imperative that there is a better understanding of the barriers to and motivators of testing for HIV infection. This study is a meta-synthesis of the qualitative literature on HIV screening and receipt of results; 128 unique publications had implications for HIV screening and receipt of results. A socioecological perspective provided an appropriate approach for synthesizing the literature. Three levels of influence emerged: individual attributes, interpersonal attributes, and broader patterns of influence. Findings were reviewed and found to have implications for continued engagement in the HIV treatment cascade. Recommendations to enhance HIV screening and to ensure receipt of results are proposed and discussed.

Voices of Women Facing HIV-Related Stigma in the Deep South

One in 139 women will be diagnosed with HIV in their lifetime. Thirty-four years into the epidemic, stigma remains part of the trajectory of the disease process for all individuals with HIV. Stigma associated with HIV makes it difficult for women to access HIV testing and counseling, disclose HIV status to sexual partners and health care providers, seek and remain actively engaged in medical care, effectively self-manage the disease after diagnosis, and adhere to antiretroviral therapy. The current article reports the qualitative results from a study designed to test the feasibility and acceptability of a technologically delivered stigma intervention for women with HIV in the Southeastern United States. Qualitative analysis revealed women with HIV uniformly experience, anticipate, and/or internalize stigma associated with HIV. Consequently, women with HIV experience isolation and a threat to self-concept as they make decisions about disclosure, work to maintain the secrecy of their HIV status, and contemplate a future.

Feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South

As with many infectious diseases throughout history, stigma is a part of the trajectory of the HIV disease process. HIV-related stigma impedes women from being tested for HIV. Once infected, HIV-related stigma hinders women from disclosing their HIV status to sexual partners and health care providers, engaging in medical care, effectively self-managing the disease after infection, and adhering to anti-retroviral therapy. After three decades of the HIV epidemic, no evidenced-based, culturally relevant, gender-specific interventions exist to help women infected with HIV manage the stigma associated with HIV infection. This manuscript reports the feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South in a mixed-method, randomized clinical trial. Results from the study demonstrate that it is feasible to utilize an iPod touch device to deliver an HIV-related stigma intervention to women. Further, women report that the HIV-related stigma intervention is acceptable and meaningful.

Fatigue in HIV-Infected People: A Three-Year Observational Study

CONTEXT

HIV-related fatigue remains the most frequent complaint of seropositive patients.

OBJECTIVES

To describe the natural course of fatigue in HIV infection, in a sample (n=128) followed for a three-year period.

METHODS

A longitudinal prospective design was used to determine what factors influenced changes in fatigue intensity and fatigue-related impairment of functioning in a community-dwelling sample of HIV-infected individuals. Participants were followed every six months for a three-year period. At each study visit, we collected data on a large number of physiological and psychosocial markers that have been shown to be related to fatigue in HIV-infected people. At three month intervals between study visits, we collected data on fatigue via mailed questionnaires.

RESULTS

Fatigue in HIV infection is largely a result of stressful life events, and is closely tied to the anxiety and depression that accompany such events. Fatigue did not remit spontaneously over the course of the study, indicating the need for interventions to ameliorate this debilitating symptom.

CONCLUSION

Intervening to help people who are suffering from HIV-related fatigue to deal with stressful life events may help to ameliorate this debilitating symptom.

Finding the New Normal: Accepting Changes After Combat-Related Mild Traumatic Brain Injury

INTRODUCTION

More than 300,000 soldiers have returned from Southwest Asia (i.e., Iraq and Afghanistan) with combat-related mild traumatic brain injuries (mTBIs). Despite less visible physical injuries, these soldiers demonstrate various physical and cognitive symptoms that impact their ability to reintegrate post-mTBI. This study explores family reintegration experiences, as described by married dyads, following a combat-related mTBI.

METHODS

Nine soldiers with mTBI and their spouses participated, and a total of 27 interviews, both joint and individual, were conducted. Strauss and Corbin's grounded theory methodology and semistructured interviews were used to collect participants' perceptions and analyze the data.

FINDINGS

The overarching theme of the reintegration experience is described as finding the "new normal." A new normal was defined by participants as the couple's new, post-mTBI expectation of the family unit or family routine. Some participants indicated that they had accepted the post-mTBI changes and were working toward this new normal, whereas others indicated these changes were unacceptable and continued their efforts to return to pre-injury functioning.

CONCLUSIONS

Individuals with mTBI and their families may benefit from interventions that directly address mismatched expectations and promote the acceptance of a new normal.

Long-term decline of the Amazon carbon sink

Atmospheric carbon dioxide records indicate that the land surface has acted as a strong global carbon sink over recent decades, with a substantial fraction of this sink probably located in the tropics, particularly in the Amazon. Nevertheless, it is unclear how the terrestrial carbon sink will evolve as climate and atmospheric composition continue to change. Here we analyse the historical evolution of the biomass dynamics of the Amazon rainforest over three decades using a distributed network of 321 plots. While this analysis confirms that Amazon forests have acted as a long-term net biomass sink, we find a long-term decreasing trend of carbon accumulation. Rates of net increase in above-ground biomass declined by one-third during the past decade compared to the 1990s. This is a consequence of growth rate increases levelling off recently, while biomass mortality persistently increased throughout, leading to a shortening of carbon residence times. Potential drivers for the mortality increase include greater climate variability, and feedbacks of faster growth on mortality, resulting in shortened tree longevity. The observed decline of the Amazon sink diverges markedly from the recent increase in terrestrial carbon uptake at the global scale, and is contrary to expectations based on models.

A randomized controlled trial of the efficacy of a stigma reduction intervention for HIV-infected women in the Deep South

The aim of this study was to compare outcomes (self-esteem, coping self-efficacy, and internalized stigma) across time in HIV-infected women living in the Deep South who received a stigma reduction intervention (n=51) with those of a control group (n=49) who received the usual care at baseline, and at 30 and 90 days. We recruited 99 women from clinics and an AIDS service organization; they were randomized by recruitment site. A video developed from the results of a qualitative metasynthesis study of women with HIV infection was loaded onto iPod Touch devices. Participants were asked to watch the video weekly for 4 weeks, and to record the number of times they viewed it over a 12-week period. We examined the trajectory model results for efficacy outcomes for the intent-to-treat and the supplemental completers groups. There was a treatment-by-time effect for improved self-esteem (intent-to-treat: p=0.0308; completers: p=0.0284) and decreases in internalized stigma (intent-to-treat: p=0.0036; completers: p=0.0060), and a treatment-by-time-by-time effect for improved coping self-efficacy (intent-to-treat: p=0.0414; completers: p=0.0321). A medium effect of the intervention in terms of improving self-esteem was observed when compared with the control condition in those who completed the study. The magnitude of the intervention effect, however, was large with regard to reducing overall stigma, improving social relationships, and decreasing stereotypes in both groups.

Managing knee ostheoarthritis: efficacy of hyaluronic acid injections

Osteoarthritis (OA) is the most common form of chronic arthritis worldwide. The etiology of pain in osteoarthritis is multifactoral, and includes mechanical and inflammatory processes. The use of intra-articular viscosupplementation in the nonoperative management of patients with osteoarthritis has become quite popular. Recent clinical data have demonstrated that the anti-inflammatory and chondroprotective actions of hyaluronic acid viscosupplementation reduce pain, from 4 to 14 weeks after injection, while improving patient function. Viscosupplements are comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events, and hyaluronic acid has more prolonged effects than IA corticosteroids. Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular hyaluronic acid injections in the treatment of osteoarthritis. We review the basic science and development of viscosupplementation and discuss the mounting evidence in support of its efficacy and safety profile.

Intensity, chronicity, circumstances, and consequences of HIV-related fatigue: a longitudinal study

HIV-related fatigue remains the most troubling complaint of seropositive people. Researchers often use tools to measure fatigue that were developed for other patient populations; thus, the measurement of fatigue specific to HIV is needed. This article describes results from the HIV-Related Fatigue Scale (HRFS) including: (a) the variability in intensity and chronicity of HIV-related fatigue, (b) the circumstances surrounding changes in fatigue, (c) the impact of fatigue on activities of daily living (ADLs), and (d) the consequences of HIV-related fatigue. We collected data every 3 months over a 3-year period from 128 people. HIV-related fatigue was chronic and did not appear to remit spontaneously; those who were the most fatigued at the beginning of the study remained the most fatigued over 3 years. Fatigue interfered more with instrumental activities of daily living than basic ADLs; it also interfered with work, family, and social life. Stress and depression increased fatigue.

Fatigue in HIV and AIDS: an analysis of evidence

HIV-related fatigue continues to be the most common complaint of infected people. No physiological factors have been consistent predictors for fatigue; psychosocial factors, particularly depression, have emerged more consistently in studies. While clinicians would want to rule out common causes of fatigue such as hypothyroidism, hypogonadism, or anemia, there is scant research for most interventions, which makes it difficult to make definitive recommendations for their use. Modafinil has the strongest research evidence to date, with multiple studies finding it effective in relieving fatigue. However, researchers must continue to pursue ways to ameliorate fatigue in HIV infection, given the high financial, personal, and social costs suffered by people experiencing it.

Integrating routine HIV screening into a primary care setting in rural North Carolina

Blacks living in the southern United States are disproportionately affected by HIV infection. Identifying and treating those who are infected is an important strategy for reducing HIV transmission. A model for integrating rapid HIV screening into community health centers was modified and used to guide implementation of a testing program in a primary care setting in a small North Carolina town serving a rural Black population. Anonymous surveys were completed by 138 adults who were offered an HIV test; of these, 61% were female and 89.9% were Black. One hundred patients (72%) accepted the test. Among those Black survey respondents who accepted an offer of testing, 58% were women. The most common reason for declining an HIV test was lack of perceived risk; younger patients were more likely to get tested. Implementation of the testing model posed challenges with time, data collection, and patient flow.

The experience and self-management of fatigue in patients on hemodialysis

Fatigue is a common and debilitating symptom for adult patients with end stage renal disease on hemodialysis, and has been associated with decreased survival and quality of life. Patients on hemodialysis must find ways to manage their fatigue and mitigate its effects on their lives. The purpose of this qualitative descriptive work was to describe the experience and self-management of fatigue in patients on incenter hemodialysis. Several themes were identified which included the nature of fatigue, management of fatigue, consequences of fatigue, and factors associated with fatigue. This information will be valuable to nephrology nurses as they continue to care for and educate patients on hemodialysis.

Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: a multiple case study

After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.