Nursing - Seattle

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The Environmental Impact on Facility-Treated Pediatric Asthma Exacerbation: A Secondary Study
(2025-10-02) Harmon, Stephen; Sonney, Jennifer
Pediatric asthma is a leading chronic disease in America; however, it is best thought of as a syndrome of airway symptoms with various etiological origins. As a result, there are numerous combinations of "triggers" that can precipitate an exacerbation in individuals who have asthma. Categorically, these triggers can range from psychosocial, such as stress and anxiety, to physical, such as pollen and pet dander. Family geographic relocations are events that can expose a child with asthma to many of these triggers simultaneously. Ecological transition is a concept within Bronfenbrenner's ecological system theory of human development, where individuals and their environments interact to produce change. The ecological transition concept accounts for aspects of the individual and the broadening layers of the environmental interaction (microsystem, mesosystem, exosystem, macrosystem, and chronosystem) in a holistic approach that allows for seemingly indirect factors to be incorporated in the development process. Through the lens of ecological transition upon the foundation of ecological systems theory, two studies were devised to examine different environmental effects on facility-treated pediatric asthma exacerbations. First, a secondary cross-sectional multilevel binomial regression (n=10,401) suggested there was no significant correlation between children of veteran parents and the likelihood of facility-treated asthma exacerbation (OR 0.96, p= .452). Second, a secondary longitudinal multilevel binomial regression (n=1,055,742) identified a significant correlation between the month of relocation and the first several months following a geographic relocation and the increased likelihood of facility-treated asthma exacerbation. Month of relocation (OR 2.10, p <.001), which is consistent with predictions from ecological transition and ecological systems theory.
Exploration of Symptom Clusters and Symptom Profiles in adults with Mild Traumatic Brain Injuries
(2025-10-02) Ziemek, Jessica; Thompson, Hilaire
Mild traumatic brain injuries (mTBIs), commonly called concussions, are caused by a bump, jolt, or blow to the head or body, leading to brain injury. Annually, approximately three million individuals in the United States seek emergency department care for traumatic brain injury, most of which are mTBIs. Recommendations for treatment and management of mTBIs are symptom dependent. However, symptom presentation and recovery trajectories are highly variable from patient to patient. Symptom clustering and patient profiling enable greater understanding of underlying pathophysiological mechanisms of symptoms and the development of targeted interventions for at risk groups. The purpose of this dissertation is to better understand symptom presentation in adults with mTBI during the subacute phase of recovery through clustering of symptoms and the grouping of individuals with common symptom presentation.
Sleep-Wake Cycles of Individuals with Inflammatory Bowel Disease
(2025-08-01) Yoo, Linda; Heitkemper, Margaret
Background: Individuals with inflammatory bowel disease (IBD), a chronic illness of the gastrointestinal (GI) system, report high rates of poor sleep quality and sleep disturbances. Among those with IBD, sleep problems are more prevalent during active disease, a period marked by inflammation and severe GI symptoms. Animal models have demonstrated that altered sleep-wake cycles and disruptions in the circadian rhythm can cause increased susceptibility to inflammation and intestinal dysbiosis. IBD studies report the association between increased GI symptoms and inflammation with less consistent daily rhythms. Limited studies have examined the social and societal factors that impact the sleep-wake cycles of those with IBD. The overall purpose of this dissertation is to explore different aspects of the sleep-wake cycles of individuals with IBD through the social-ecological model of sleep (SEM).Methods: In this prospective cohort study, 50 participants were recruited from an IBD clinic in Seattle, WA. Individuals collected wrist actigraphy for 10 days, a stool sample, baseline surveys, and daily electronic diaries. 24 of the 50 participants completed semi-structured interviews. The aim of manuscript one was to examine the relationship between sleep and fatigue outcomes (i.e., PROMIS sleep disturbance and fatigue, Pittsburgh Sleep Quality Index), GI symptoms (i.e., abdominal pain, bloating, diarrhea, constipation, nausea), and fecal calprotectin with rest-activity rhythm (RAR) characteristics and social jetlag (SJL). RAR characteristics and SJL were analyzed from wrist actigraphy. Fecal calprotectin, a biomarker of gut inflammation, was measured using ELISA assays from the stool samples. Survey data used were sleep and fatigue outcomes and GI symptoms from daily diaries. In manuscript two, generalized estimating equations (GEE) was used to test if sleep fragmentation from wrist actigraphy and self-reported sleep quality from daily diaries predicted next-day GI symptoms (i.e., abdominal pain, bloating, diarrhea, constipation, nausea). For manuscript three, a hybrid thematic analysis was used to explore factors across the individual, social, and societal levels that impact sleep-wake cycles of those with IBD, and describe the strategies used to improve sleep health. Results: There were no significant relationships between RAR characteristics and SJL with sleep, fatigue, GI symptoms, and fecal calprotectin. The midline estimating statistic of rhythm (MESOR) and relative amplitude were higher in those in remission than those with clinically active disease. Sleep fragmentation and self-reported sleep quality were non-statistically significant predictors of next-day GI symptoms. Among the participants, wake after sleep onset was higher, and sleep efficiency was lower than the recommendations from the National Sleep Foundation. The factors and strategies that impact sleep-wake cycles were three individual-level themes (7 subthemes) and three social-level themes (4 subthemes). The individual-level themes were lifestyle and behaviors (daytime behaviors and habits, nighttime influences, diet, and technology use), physical health (IBD and GI symptoms; non-GI pain, fatigue and other health conditions; medications and supplements), and mental health. The social-level themes were sleep environment, interpersonal relationships (partner, children, pets, friends) and work. Participants provided strategies that both directly and indirectly positively impacted sleep health. Conclusion: In this study, participants in clinical remission had more robust rest-activity rhythms than those in active disease. There is an opportunity for improvements in nighttime sleep (e.g., sleep efficiency, wake after sleep onset) despite the sample’s average total sleep time and sleep onset latency meeting recommendations by the National Sleep Foundation. Future multilevel sleep interventions in the IBD population should accommodate not only individual-level factors but also social-level factors that impact sleep-wake cycles. Although the social-level factors identified in the study might not be modifiable in the lives of those with IBD, it is important to account for these factors when creating tailored interventions. Future studies should examine different aspects of the circadian rhythm (e.g., chronotype, dim light melatonin onset) and the peripheral intestinal clock alongside individual-level IBD health outcomes, such as inflammation and GI symptoms, and social-level factors.
Sleep, Cognition, Psychological Symptoms, and Health-Related Quality of Life Among Heart Transplant and Left Ventricular Assist Device Recipients
(2025-08-01) Zheng, Tao; Dougherty, Cynthia
Heart failure (HF) is a chronic, progressive condition affecting an estimated 6.7 million Americans over age of 20. For individuals with advanced HF, treatment options such as heart transplantation (HTx) and left ventricular assist devices (LVADs) can significantly improve survival and health-related quality of life (HRQOL). Despite these interventions, many individuals continue to face persistent physiological and psychological challenges, including sleep disturbances, cognitive impairments, and psychological symptoms, which may hinder recovery and adversely affect overall well-being and HRQOL. The overarching purpose of this dissertation is to examine changes in sleep, cognition, psychological symptoms, and HRQOL from hospital discharge to 3 months post-discharge, and to explore interrelationships among these health outcomes in individuals who have received a LVAD or HTx. Specifically, the aims of this dissertation are to: 1) Conduct a comprehensive literature review on neurocognitive changes associated with HF, 2) Describe changes in objective and subjective sleep quality, cognition, psychological symptoms, and HRQOL from hospital discharge to 3 months post-discharge following a LVAD implant or HTx, 2) examine relationships between changes in sleep and changes in cognitive function, psychological symptoms, and HRQOL, and 3) Explore patient experiences, challenges, and perspectives on changes in sleep quality and its perceived impact on cognition, psychological wellbeing, and HRQOL during the initial 3 months post-discharge after LVAD or HTx. By characterizing these outcomes and their interconnections, this study provides novel insights into post-operative recovery in both LVAD and HTx recipients. The findings highlight critical gaps in current understanding, underscore the need for further research, and offer preliminary evidence to guide the design of future large-scale, multicenter studies. This work lays a foundation for improving care strategies and supporting multidimensional recovery in these growing patient populations.
Impact of ICD Indication and the P+P Intervention on Intimate Partner Physical and Mental Health
(2025-08-01) CHANG, WEILUN; Dougherty, Cynthia
Purpose/Aims: This dissertation examined the impact of the Patient+Partner (P+P) intervention on physical and psychological outcomes of partners of patients with implantable cardioverter defibrillators (ICDs), compared to a Patient-only (P-only) intervention. The study investigated whether: 1) partner demographic characteristics moderate intervention effects at 3 months; 2) self-efficacy mediates outcomes at 12 months; 3) patient ICD indication influences intervention effectiveness across a 12-month trajectory; and 4) evaluated measurement instruments used to assess partner outcomes in ICD contexts. Methods: This research includes: 1) secondary analysis of data from a randomized controlled trial (N=301 patient-partner dyads) from 12 acute care institutions across four states; 2) hierarchical regression for moderation analysis and path analysis for mediation testing; 3) General Linear Model with repeated measures for longitudinal analysis; and 4) systematic review of 17 quantitative studies (1990-2025) measuring partner outcomes following ICD implantation. Partner outcomes were assessed at baseline, 1-, 3-, 6-, and 12-month timepoints using validated instruments measuring physical function, psychological adjustment, relationship impact, and self-efficacy. Results: While demographic characteristics did not moderate intervention effects, self-efficacy at 3 months significantly mediated 12-month outcomes, with the P+P intervention enhancing partner self-efficacy (β=0.13, p=0.003), which subsequently improved physical health (β=0.11, p=0.018), mental health (β=0.24, p<0.001), reduced anxiety (β=-0.42, p<0.001) and depression (β=-0.22, p<0.001). Significant timeÃ ICD indication interactions emerged for mental health at 3 months (F=4.400, p=0.005) and 12 months (F=3.948, p=0.009), with partners of secondary prevention patients showing greater improvement in the P+P group. A significant three-way interaction (timeÃ ICD indicationÃ intervention) was observed for relationship quality at 12 months (F=2.667, p=0.048). The systematic review revealed significant methodological limitations in partner assessment, including insufficient physical health measurement and limited cardiac-specific instrumentation. Conclusion: The P+P intervention improves partner outcomes primarily through enhancing self-efficacy, with differential effectiveness across ICD indication categories. Partners of secondary prevention patients demonstrated particular vulnerability at baseline but achieved substantial improvement with the P+P intervention. The findings underscore the importance of partner-inclusive intervention in cardiac care, the necessity of tailoring interventions to specific clinical contexts, and the need for comprehensive, contextually-relevant measurement instruments for partner assessment.
ICU Delirium Prevention for Patients Who Speak a Language Other Than English
(2025-08-01) Ahrens, Emily; Thompson, Hilaire
Background: Delirium acquired in the intensive care unit, ICU delirium, is a common neurologic sequela of critical illness, affecting up to 70% of patients. The incidence and duration of ICU delirium is associated with increased mortality, increased hospital length of stay, and increased healthcare costs. After hospital discharge, having experienced ICU delirium is independently associated with long-term cognitive impairment and post-traumatic stress disorder. ICU delirium prevention depends on effective communication to complete complex interventions. Due to a language barrier adding to communication challenges, critically ill patients who speak a language other than English (LOE) may be at higher risk for ICU delirium. Gaps in our knowledge perpetuate inequitable access to evidence-based interventions and disparities in outcomes for LOE patients. Purpose: This dissertation aims to examine how language barriers experienced by LOE critically ill patients influence adherence to ICU delirium prevention interventions. Methods: The first study (Chapter 2) describes and compares ABCDEF bundle fidelity for critically ill LOE patients to English-speaking patients by performing secondary data analysis of the Society of Critical Care Medicine (SCCM) ICU Liberation Dataset of ABCDEF bundle completion. The second study (Chapter 3) describes facilitators and barriers to implementing delirium interventions among critically ill LOE patients using qualitative thematic analysis. The third study (Chapter 4) assesses the acceptability, feasibility, and appropriateness of the VidaTalk™ application as an implementation strategy to increase the reach of the ABCDEF bundle to LOE ICU patients using convergent a mixed-methods study design. Results: In Chapter 2, We found that the odds of adherence to the A, E, and F elements were statistically significantly higher for LOE patients compared to English speaking patients, while the odds of adherence to the C and D elements were significantly lower for LOE patients compared to English-speaking patients. Additionally, LOE patients had a longer length of stay, longer length of mechanical ventilation, and higher odds of mortality compared to English-speaking patients. These findings indicate a disparity in the ABCDEF bundle those results in worse healthcare outcomes for LOE patients. In Chapter 3, The analysis revealed barriers on the institutional, unit, and individual levels. The institutional level barriers included limited access to interpreter devices, technological issues with the interpreter devices, and communication lags during interpretation. Unit level barriers included time constraints due to staffing and unit culture. Individual barriers included biases reducing use of interpreters and taking shortcuts, healthcare worker inexperience, lack of knowledge regarding the ABCDEF bundle and cultural humility. The facilitators on the institutional level included the resources and training provided to improve cultural humility and interpretation. The unit level facilitators include adequate staffing, easy access to interpreters, and high expectations of adherence to ABCDEF bundle elements. Individual facilitators were experienced health care workers (HCWs) who had knowledge of the benefits of the ABCDEF bundle elements and therefore prioritized them for patients regardless of language. In this chapter, we highlight major challenges to communication with LOE patients experience by HCWs and LOE ICU survivors alike. These challenges contribute to reduce quality and adherence to the ABCDEF bundle for LOE patients. In Chapter 4, the VidaTalkTM device was found to be acceptable, feasible, and appropriate for use with critically ill LOE patients. Healthcare workers liked the device because it was easy to use, enabled fast basic communication, empowered patients to express their needs, and had many preset phrases that were targeted toward the ABCDEF bundle elements. However, HCWs were concerned that patients who were already delirious would not be able to use the device. They also wanted more pre-set caregiver responses, categorized by bundle element, that would enable them to easily speak back to the patient. Conclusion: LOE patients experience health disparities in care and outcomes in the intensive care unit. The barriers prevent HCWs from being able to implement ABCDEF bundle measures with fidelity. The facilitators address the barriers, but do not overcome them entirely. Future research on generating interventions to enhance effective communication at the beside between LOE patients and English-speaking HCWs is necessary.
Cross-Sector Collaborations in Public Health for Promoting Physical Activity, Advancing Health Equity, and Reducing the Prevalence of Chronic Disease in the U.S.
(2025-08-01) Brinker, Kimberly; Bekemeier, Betty
Rates of chronic diseases such as obesity and diabetes are on the rise in the U.S. disproportionately impacting the Hispanic population. At the local level, public health services research has been focused on the impact of local health department (LHD) performance on improving population health outcomes. State health departments (SHDs) also engage in promoting health equity and reducing chronic disease disparities through cross-sector collaborations, but gaps in the literature exist regarding factors that promote the effectiveness and sustainability of such efforts. Yet, health department engagement could affect performance in and the sustainability of cross-sectoral public health initiatives. This dissertation aimed to explore how the current public health infrastructure within the U.S. can support the engagement and sustainability of cross-sectoral collaborations for promoting physical activity, advancing health equity, and reducing the prevalence of chronic disease. To add to the existing literature, we utilized the Cross-Sector Alignment Theory of Change and the Chronic Disease Prevention/Healthy Living Promotion (CDP/HLP) Framework to design a multi-method research study for examining cross-sectoral collaborations. We examined formal, written strategies (FWS) in association with LHD engagement in cross-sectoral collaborations for obesity prevention. We conducted a quantitative analysis to determine relationships between a FWS for obesity prevention and the level of LHD engagement in cross-sector collaborations targeting health promotion. Then, LHDs identified as either highly or moderately engaged in obesity prevention efforts were purposively sampled for a qualitative analysis to identify factors within LHDs that assist in maintaining engaged and sustainable cross-sector collaborations that promote PA, particularly for the Hispanic community. Finally, an additional qualitative analysis aimed to (1) explore specific characteristics of existing collaborations between SHD and external organizations that promote the engagement and sustainability of health equity initiatives and (2) identify organizational strategies that SHD staff and partners perceive to be successful in addressing chronic disease disparities through cross-sectoral collaborations. The studies described here utilized frameworks to evaluate the impact of health department engagement on outcomes and organizational strategies to support the engagement and sustainability of cross-sectoral partnerships. In each study, findings support the need for resource and capacity building, particularly in smaller health departments that serve rural areas. For LHDs prioritizing marginalized populations, there is a need to integrate the social determinants of health (SDOH) into culturally appropriate interventions through partnerships with community-based organizations. When examining state-level organizational strategies for ensuring engagement and the sustainability of cross-sectoral collaborations, public-private partnerships (PPPs) were key to increasing organizational capacity to develop and maintain health equity initiatives that strive to reduce chronic disease disparities.
Leadership in Public Health: Development, Cross-Sector Collaboration, and Mental Health Among U.S. Public Health Leaders
(2025-08-01) Martelino, Janelle Zamora; Bekemeier, Betty
The U.S. public health system faces mounting challenges that demand resilient leadership and greater integration across sectors. Despite longstanding calls to bridge public health and primary care, systemic fragmentation persists, and public health leaders continue to face heightened psychosocial strain. This dissertation explores public health leadership development, intersectoral collaboration, and the organizational conditions that shape public health leader mental health. Employing a three-paper format, this study integrates qualitative and quantitative approaches to examine how collective efficacy and organizational climate may serve as levers for leadership development and healthy working environments.Paper 1 explores the experiences of public health and primary care leaders participating in an interprofessional leadership development program. Through qualitative interviews, participants described individual- and collective-level changes, including shared mental models, dissolution of previously held beliefs about the other sector and shifts in collective identity. These findings underscore the behavioral and affective underpinnings of collective efficacy in public health leadership. Paper 2 constructs a conceptual framework for collective leadership development. The framework articulates a developmental model in which leadership is cultivated through supportive structures, shared accountability, and intentional investment in relationship-centered practice. The model offers practical guidance for leadership programs aiming to build workforce capacity for systems change. Paper 3 employs a multilevel analytic approach to examine the association between role-related harassment and mental and emotional health among public health leaders, using data from the 2021 Public Health Workforce Interests and Needs Survey (PH WINS). Drawing on Lazarus and Folkman’s transactional model of stress and Hobfoll’s conservation of resources theory, the study assesses whether organizational climate moderates the negative effects of harassment. Findings reveal that leaders exposed to role-related harassment report significantly worse mental health, but that supportive organizational climates may buffer these effects. Taken together, these studies advance an integrated understanding of public health leadership that centers collective efficacy, prioritizes organizational conditions, and addresses psychosocial threats to public health leader mental health. The dissertation contributes actionable insights for leadership development, workforce resilience, and capacity for systems-level transformation in the public health sector.
Evaluating Determinants and Strategy Implementation of the Single-Visit Screen and Treat Approach with Thermal Ablation in Kenya
(2025-08-01) Adhiambo, Harriet Fridah; Gimbel, Sarah
Introduction: The availability of effective cervical cancer prevention interventions creates a clear pathway towards elimination. However, cervical cancer remains the leading cause of cancer-related deaths among women in low- and middle-income countries, primarily attributed to persistent implementation gaps. This dissertation explores the implementation of the single-visit, screen and treat approach with visual inspection with acetic acid (VIA) and thermal ablation (SV-SAT+TA) by identifying key determinants, characterizing provider-led strategy adaptations, and evaluating the alignment between implementation strategies and contextual barriers. Methods: This dissertation is nested within a hybrid type III implementation trial aimed at developing and evaluating implementation strategies to support the national scale-up of the single-visit screen and treat approach using VIA and thermal ablation across 10 health facilities in Kenya. Chapter 2 used qualitative methods to identify barriers and facilitators to the implementation of the SV-SAT+TA among 34 participants: 20 frontline health care providers, 10 health facility managers, and 5 policymakers. In-depth interviews were conducted and guided by the adapted Consolidated Framework for Implementation Research (CFIR) for LMICs. In Chapter 3, we applied the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to systematically document and track adaptations to the TIBA implementation strategies across the 10 health facilities. FRAME-IS guided the development of the Excel tracking sheets. Data was collected monthly by Technical Assistants through site visits, direct observations, and field notes. Chapter 4 employed a convergent mixed-methods approach to evaluate barrier-strategy matching using surveys and small group discussions with 40 participants, mainly frontline healthcare providers and facility managers. Results: Findings from Chapter 2 identified leadership engagement, the relative advantage of thermal ablation over cryotherapy, and self-efficacy among providers as drivers of successful SV-SAT+TA implementation. Conversely, lack of essential commodities, infrastructural limitations, shortage of trained staff, and recruitment challenges emerged as barriers to implementation. Building on Chapter 2, findings from Chapter 3 revealed that most adaptations occurred early in implementation and were primarily education (57%) and resource-related (21%). Adaptations mainly targeted provider adoption of the SV-SAT+TA, and the rate of adaptations declined over time. In Chapter 4, we found that 71% of the pre-identified barriers were successfully addressed through well-matched strategies focusing on improving clinic workflows, training, and community engagement. However, structural issues such as staffing, client follow-up remained inadequately addressed. Conclusion: This dissertation provides critical insights into the contextual and system-level factors influencing the implementation of cervical cancer prevention interventions in Kenya. The lessons learned have a broad relevance for scaling and sustaining cervical cancer prevention efforts across LMICs.
Healthcare Resource Utilization and Costs in Patients with AML Treated with Post-Transplant Maintenance Therapy
(2025-08-01) Kneitel, Rachel; Kreif, Noemi
AbstractHealthcare Resource Utilization and Costs in Patients with AML Treated with Post-Transplant Maintenance Therapy Rachel Kneitel Chair of the Supervisory Committee: Noemi Kreif Pharmacy Background: Allogeneic hematopoietic cell transplantation (allo-HCT) has improved survival in patients with acute myeloid leukemia (AML); however, post-transplant relapse remains the most common cause of treatment failure and death. There is limited data regarding the economic and clinical burden associated with the progression from diagnosis to post-transplant maintenance therapy, which is intended to maintain remission in patients. Objective: To describe healthcare resource utilization (HRU) and quantify costs among commercially insured, Medicaid, and Medicare beneficiaries who have and have not received maintenance therapy after allo-HCT. Methods: We conducted a retrospective cohort study on commercially insured, Medicare, and Medicaid beneficiaries with AML who were and were not prescribed maintenance therapy following allo-HCT between October 1st, 2015 and March 31st, 2024 using claims from the Merative MarketScanÂ® database. The final analytic cohort included 373 patients, of whom 43 were prescribed maintenance therapy following allo-HCT. To account for observed differences between those who received maintenance therapy and those who only received allo-HCT, we employed inverse probability weighting (IPTW) using propensity scores estimated from baseline characteristics. We assessed differences in all-cause monthly HRU by summarizing the number of emergency department (ED), inpatient (IP), outpatient (OP) visits, and hospital length of stay throughout the 12 month follow up period. We also evaluated monthly supportive therapy utilization patterns, including therapies that stimulate neutrophil production to reduce infection risk and promote red blood cell production to manage anemia, to assess treatment-related care requirements. Poisson regression models were used to estimate monthly event rates for each HRU category. Total healthcare costs were reported as the sum of ER, IP, OP, and outpatient pharmacy costs to provide insights into the costs associated with maintenance therapy. Transfusion burden was evaluated by counting the number of transfusions for each cohort. Results: The maintenance therapy group demonstrated significantly higher HRU across multiple service types. Office visits were more than doubled (IRR = 2.11, p < 0.001), with significant increases in IP visit rates (IRR = 1.39, p = 0.015), hospitalization rates (IRR = 1.37, p = 0.024), and overall OP utilization (IRR = 1.79, p < 0.0001). Specialist clinic and ED visit rates were higher but not statistically significant (IRR = 1.5, p = 0.151; IRR = 1.75, p = 0.309), respectively. Supportive therapy utilization peaked within the first three months post-transplant in the maintenance therapy group before converging with controls by month eight. Healthcare costs were driven primarily by IP expenses, with the maintenance therapy group incurring substantially higher costs four to ten months after allo-HCT. Pharmacy costs were expectedly higher in the maintenance therapy group throughout follow-up. Blood transfusion requirements were minimal in both groups, with 93% of maintenance therapy patients and 97.6% of allo-HCT only patients requiring no transfusions during the 12-month follow-up period. The mean monthly length of stay was significantly longer in the allo-HCT only group compared to the maintenance therapy group (33.77 Â± 31.49 days vs. 20.97 Â± 15.36 days), with a mean difference of 12.72 days (95% CI: 11.14,14.31; p = 0.001). Discussion: Our findings show that those who received maintenance therapy following allo-HCT were associated with having significantly greater healthcare resource utilization and costs, as shown by higher rates of office visits and hospitalizations. IP visits accounted for the largest share of monthly healthcare expenditures, with the maintenance group incurring notably higher IP costs from months four to ten after allo-HCT. Pharmacy costs were the second largest component and were consistently higher in the maintenance group. Supportive therapy use was substantially higher in the maintenance group during the early post-transplant period, peaking within the initial three months. These findings highlight the need to balance the clinical benefits of maintenance therapy with its increased demands on healthcare resources.
Exploring the Causes, Magnitude, and Implications of Discrepancies in Objective and Subjective Sleep Measures in Women in the Menopause Transition and Postmenopause
(2025-01-23) Park, In Hye; Reding, Kerry
Over half of women undergoing the menopausal transition (MT) or postmenopause (PM)experience significant sleep disturbances due to aging, hormonal changes, hot flashes, and night sweats. These issues can severely affect mental health, daily functioning, and overall quality of life. Poor sleep quality during these stages is linked to increased risks of anxiety, depression, and reduced productivity. Accurate assessment of sleep is vital but challenging, as subjective tools like questionnaires often differ from objective methods such as polysomnography (PSG) and actigraphy. However, discrepancies between subjective and objective measures highlight the need for combined approaches to capture the full complexity of sleep disturbances in MT and PM. Despite growing research, the unique sleep challenges faced by women in these stages remain underexplored, emphasizing the importance of targeted studies to inform effective interventions—a gap this dissertation aims to address. This dissertation investigates the discrepancies between subjective and objective sleep assessments in menopausal and postmenopausal women, offering critical insights into how physiological, psychological, and stress-related factors contribute to sleep disturbances. By examining these issues through subjective and objective measures, it emphasizes the need for nuanced approaches in both research and clinical practice, structured around three main topics (Chapters 2, 3, and 4). Chapter 2 reviews 16 studies (2010–2022) that highlight consistent patterns of subjective sleep assessments overestimating total sleep time (TST) and sleep onset latency (SOL) while reporting more nighttime awakenings (WASO) compared to objective measures like PSG and actigraphy. These discrepancies arise as subjective measures reflect personal perceptions—often influenced by menopausal symptoms such as vasomotor symptoms (VMS) and heightened emotional sensitivity—while objective tools provide a more precise account of physiological sleep patterns. This chapter underscores the importance of integrating both methods to capture the multifaceted nature of sleep disturbances, laying the foundation for targeted clinical interventions. Chapter 3 explores how insomnia amplifies the misalignment between subjective and objective sleep measures. Using data from the Finding Lasting Answers for Symptoms and Health (MsFLASH) research network, it examines key sleep parameters (TST, SOL, WASO, and sleep efficiency [SE]) across actigraphy, PSQI, and sleep diaries. Results show that women with insomnia experience greater perceptual discrepancies, often overestimating TST and SE while underestimating SOL and WASO compared to objective data. These biases are more pronounced in PSQI scores, likely due to recall errors inherent in retrospective reporting. The findings highlight insomnia’s role in altering sleep perception through mechanisms such as heightened cortical activation and impaired sensory processing, emphasizing the need for combined assessment methods to accurately evaluate sleep in menopausal populations. Chapter 4 investigates how VMS and stress influence discrepancies in sleep assessment. Using MsFLASH data, the study evaluates SOL, TST, WASO, and SE through actigraphy, PSQI, and sleep diaries, while also considering perceived stress and physiological stress via nighttime salivary cortisol. Results reveal that VMS contributes significantly to overestimations of SOL and WASO and underestimations of TST and SE in subjective reports, particularly PSQI, highlighting the impact of symptom-driven perceptual biases. While perceived stress affected SOL discrepancies, physiological stress (cortisol) showed no consistent relationship, questioning its reliability as a stress marker in sleep studies. This chapter advocates for integrating actigraphy with sleep diaries for a more accurate depiction of sleep patterns in women with VMS and stress, cautioning against overreliance on PSQI for nuanced sleep assessments. This research highlights the interplay between menopausal symptoms and sleep perception, advocating for multifaceted assessment strategies to enhance clinical practices. This dissertation underscores the importance of adopting a comprehensive, multi-method approach to evaluating sleep disturbances in menopausal and postmenopausal women. By exploring the discrepancies between subjective and objective sleep evaluations, it reveals the shortcomings of relying solely on single-method assessments to understand the intricate interaction between physiological and perceptual elements of sleep. Factors such as VMS, insomnia, and stress play a significant role in shaping these discrepancies, emphasizing the value of dual-method approaches that combine objective measurements with subjective accounts.
Goodbye UTI (GUTI): Prototyping A Digital Intervention to Support Dementia Family Caregivers with Urinary Tract Infection Prevention and Management
(2025-01-23) Wu, Kuan-Ching; Zaslavsky, Oleg
Urinary tract infections (UTIs) are a leading cause of potentially preventable hospitalizations for persons living with dementia (PLWD), significantly increasing caregiver burden and healthcare costs. This dissertation proposes the development of Goodbye UTI (GUTI), a digital intervention designed to assist family caregivers (FCGs) in preventing, managing, and tracking UTIs in PLWD. Given the unique challenges of dementia care, where PLWD often cannot express urinary discomfort, caregivers face difficulties in recognizing early symptoms and ensuring timely treatment. The goal of GUTI is to bridge this gap through an accessible digital tool that empowers caregivers by providing clinical guidance, symptom tracking, and educational content aligned with UTI prevention guidelines.The paper followed the three-paper dissertation format and was structured into three phases, following a human-centered design (HCD) approach. In the first phase, a comprehensive conceptual framework for UTI prevention and management was created, informed by a scoping review of the literature and the Centers for Disease Control and Prevention’s (CDC) four-tiered Social Ecological Model. The second phase examined the current digital interventions for UTI prevention and management in PLWD and their FCG through a comprehensive scoping review. By analyzing various study designs, intervention types, frameworks, and operation methods, we aimed to inform the development of a more effective, tailored prototype that better serves the needs of PLWD and their caregivers. The final phase involved identifying the context of use, user needs and preferences through interviews and surveys with main stakeholders, especially FCGs. These insights will inform our future study regarding the design of the GUTI prototype, tailored to the specific requirements of caregivers managing PLWD with moderate to late-stage dementia. The GUTI digital intervention aims to alleviate caregiver burden by equipping FCGs with tools to manage urinary health for their loved ones more effectively. This digital support could potentially reduce UTI-related emergency department visits and hospitalizations among PLWD. As a scalable, home-based solution, GUTI has the potential to enhance the well-being and quality of life for both caregivers and PLWD. If successful in reducing caregiver burden, improving urinary health management, and lowering emergency visits and hospitalizations, GUTI could serve as a model for developing similar digital health solutions to address other challenges in dementia care.
The Relationships among Diet, Bacterial Taxa, Fecal Short Chain Fatty Acids (SCFA) and Symptoms among Healthy Women and Women with Irritable Bowel Syndrome
(2024-10-16) Utleg, Angelita Gaoiran; Heitkemper, Margaret
Irritable bowel syndrome (IBS) is the most prevalent gastrointestinal (GI) disorder in western developed countries exerting a tremendous economic, social, and emotional burden. IBS, a disorder of gut-brain interaction (DGBI), characterized by abdominal pain and altered bowel habits, is one of the top 10 reasons for primary care consultations. IBS affects nearly 35 million Americans (10% to 15% adults), incurring $20 billion in direct and indirect expenditures. Sex is a major risk factor for IBS; women experience more visceral pain and hypersensitivities than men. Two-thirds of the IBS population in the US are women, the majority in their reproductive years, and tend to report psychological comorbidities (anxiety and depression). Most of the IBS population seek multiple, conventional treatments to manage their IBS symptoms. There is increasing evidence for the effectiveness of a high fiber diet in reducing IBS symptoms, especially constipation. How a high dietary fiber (DF) intake affects IBS symptoms at a molecular level is not clear. Several studies have shown strong, empirical evidence that diet modifies the gut microbiome, however additional clinical research is warranted to confirm these laboratory findings. This study employed secondary analysis for the purpose of exploring the relationships between fecal short chain fatty acids (SCFA) and IBS clinical symptoms (i.e., constipation, diarrhea, abdominal pain), stool microbiome (based on 16S ribosomal DNA data), and DF intake, as well as in comparison group of healthy controls (HC). The results add to the evidence base for higher fiber intake as an effective therapeutic intervention for the management of IBS symptoms, strengthen current evidence of the presence of gut dysbiosis in IBS, and could further advance nursing science and symptom management. The long-term goal of this line of research was to fill the gaps as described above. The specific aims of this research study included: Aim1) To compare fecal SCFA concentrations (millimolar) between IBS and HC groups. Aim 2) Separately within each IBS bowel pattern subgroup (IBS-C, IBS-D) and HC, determine the associations between (2a) SCFAs and GI symptoms, (2b) SCFAs (millimole) and DF (soluble and insoluble in grams) intake, (2c) DF (soluble and insoluble in grams) and GI symptoms (diarrhea, constipation, pain) and Aim 3) To explore the relationships of fecal SCFA metabolites with fecal bacteria taxa at the genus level in IBS bowel pattern subgroups (IBS-D and IBS-C) and HC groups. Hypotheses tested included: 1) IBS cohorts regardless of bowel group will have reduced fecal SCFA compared to HC (Aim 1); 2) lower total SCFA will be associated with higher abdominal pain severity (Aim 2a); 3) higher total SCFA will be associated with diarrhea, while lower total SCFA will be associated with constipation (Aim 2a). It was also expected that a DF intake above 25g/day will have higher SCFA fecal concentration as compared to <25g/day (Aim 2b). Also, a high and rapidly fermentable and soluble DF intake will be positively correlated with fecal SCFA concentrations and IBS abdominal pain severity (Aim 2c). Higher intake of insoluble and slowly fermentable DF intake will be associated with lower abdominal pain (Aim 2c). Aim 3 is exploratory. Given the nature of this study, causality cannot be established; however, this study provides some degree of evidence that gut dysbiosis exists in women with IBS in this sample. Current knowledge claims that humans and the gut microbes are co-dependent with each other and alteration in gut microbiome has been associated with several inflammatory disorders including IBS. Confirmation of microbiome signature in IBS; however, is still ongoing and this observational study helps affirm some of these biological signatures. Specifically, this study found positive associations of high fecal butyrate concentration and reduced GI symptoms and non-GI symptoms in women with IBS. This finding is important because IBS is a gut-brain interaction disorder and currently, there is limited research in investigating the links of psychological distress symptom markers and the gut microbiome in IBS. This study supports the idea that gut commensals are indispensable to health and since diet modulates the gut microbiome, the development of evidence-based personalized dietary interventions is key in managing IBS symptoms. The generated fecal metabolomics data provided valuable information about mechanisms in which the microbiome influences clinical symptoms of IBS.
Supporting Adherence and Viral Suppression Goals for Adolescents and Young Adults Living with HIV in Kenya
(2024-10-16) Oja, Deepa; Kohler, Pamela
Background: Achieving viral suppression goals for adolescents living with HIV (ALHIV) requires individual adherence to ART and efficient and effective health systems to monitor viral load (VL) and coach adolescents when adherence falters. The purpose of this three-study dissertation is to understand individual and health systems drivers of adherence and VL monitoring among ALHIV in Kenya. Aim 1 sought to assess if VL results are available in EMR and ALHIV knowledge of their VL results. Aim 2 sought to identify factors impacting the return of VL information to clinics and clients and how healthcare providers make decisions on when to repeat confirmatory VL testing. Aim 3 measured adherence self-efficacy to ART at an individual level and evaluated the relationship between ART adherence self-efficacy, viral suppression, and its predictors. Methods: 1. We compared VL results of ALHIV aged 15-19 available in the National Database and compared them to clinic-based electronic medical records (EMR) for accuracy and completeness at six facilities in Kiambu and Nakuru counties. Additionally, ALHIV attending care at these facilities participated in exit surveys, and the modified Poisson regression model assessed the relationship between ALHIV characteristics and knowledge of VL results. 2. We conducted focus group discussions and in-depth interviews with purposively selected healthcare providers from various phases of VL information flow. 3. We further analyzed baseline data from a longitudinal cohort of Kenyan ALHIV enrolled in the Data-informed Stepped Care study to assess correlates of ART adherence self-efficacy and HIV viral suppression. Mixed effects regression models, clustering for facility, assessed associations between HIV adherence self-efficacy scores, viral suppression, and predictors of interest. Results: 1. Of 207 charts that were randomly selected, 86% (n=179) of the VL matched National Database source records; however, ≥ 10% of VL results were missing in the EMR or incongruent with the National Database source. Out of 132 ALHIV who participated in the survey, only half (52%) reported receiving their last VL result, and older ALHIV (18-19 years) were more likely to receive their test results than younger ALHIV (15-17 years). 2. Identified themes from facility staff were: (1) individual and family level challenges and (2) facility-level challenges to obtaining VL samples, (3) facility-developed strategies to improve sample collection, (4) supply chain constraints affecting laboratory-related delays, (5) lack of VL information affecting treatment decisions, (6) client-specific factors impacting return of VL results, and (7) first healthcare providers to address non-suppressed VL were adherence counselors (8) reluctance to repeat VL until adherence challenges are resolved and (9) measuring adherence through subjective means. 3. Among 1,033 ALHIV, those with no or mild depressive symptoms had higher HIV-adherence self-efficacy (HIV-ASES) scores than those with moderate-to-severe depressive symptoms. ALHIV with high perceived social support scores had higher odds of suppressed viral loads than those with low social support. Although not statistically significant, ALHIV with high adherence self-efficacy scores more frequently had suppressed viral loads compared to those with low levels of adherence self-efficacy scores. Conclusion: To meet viral suppression goals, interventions that support ALHIV VL knowledge and mental health, combined with efficient health systems processes such as mobile tools, are necessary.
Navigating the World: Understanding Gender Expression through the Experiences of Transgender and Nonbinary People
(2024-10-16) van Winkle, Teresa M; Altman, Molly R
Transgender and nonbinary (TNB) people in the United States face daily discrimination and violence due to their minoritized gender resulting in disproportionately high rates of psychological distress including but not limited to depression, anxiety, and suicide. Current research into these experiences focuses on gender, however, this does not provide a complete picture of the lived experiences of TNB people. Gender expression is the external manifestation of not only gender but a multitude of other factors and is influential in how people are perceived and subsequent discrimination and violence. The overarching goal of this study is to ascertain the process of gender expression for TNB people and describe the associated factors. The dissertation is comprised of three distinct but interrelated analyses. The first paper consists of a principle-based concept analysis clarifying the concept of gender expression. Health science literature, along with historical fiction and current writings from Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) authors provided the data for the analysis. The second paperutilizes constructivist grounded theory and dimensional analysis to explore the process of gender expression through interviews with TNB people (n=28). Using the data from Paper Two, the third paper employs situational analysis to map and understand the external influences on the gender expression process. Findings from this study support the need to include gender expression along with gender when conducting research with TNB communities. Additionally, this study proposes a new conceptualization of the Gender Minority Stress Model to better align with TNB experiences.
Exploring Implementation Strategies to Improve Pediatric Treatment Guideline Implementation: Understanding Factors, Co-designing Strategies, and Identifying Change Mechanisms
(2024-10-16) Coe, Megan; Gimbel, Sarah
Background: While substantial progress has been made towards reducing child mortality, millions of preventable child deaths continue to occur every year. Clinical treatment guidelines that describe evidence-based interventions are available, however adherence to them remains suboptimal. This dissertation explores implementation strategies to support guideline adherence among health workers providing care in hospital settings in Kenya and other low- and middle-income countries (LMICs).Methods: This dissertation utilized several methods to identify factors impacting guideline implementation, co-design a strategy to improve adherence, and identify the mechanisms that generate changes in guideline adherence. In Chapter 1, a qualitative study was conducted to understand the barriers and facilitators of clinical treatment guideline adherence among health workers at two hospitals in Kenya. Interviews and focus group discussions were conducted, transcripts were coded with a codebook organized around the Theoretical Domains Framework (TDF), and analysis identified themes. In Chapter 2, we utilized a complex mixed method design to build upon the understanding gained in Chapter 1 and co-design an implementation strategy that would support health workers in applying clinical treatment guidelines at one hospital in Kenya. Through a multi-stage process of group decision making and iterative design, the Team Approach to Malnutrition Services (TeAMS) Toolkit was developed. Following a 10-week pilot of this strategy, a mixed methods evaluation of usability, feasibility, and impacts on task completion and teamwork was conducted. A survey included measurement of the System Usability Score, Feasibility of Implementation Measure as well as task analysis, and teamwork perceptions; with interviews and focus group discussions exploring these concepts in detail. In Chapter 3, a realist literature synthesis was conducted to develop and refine a program theory that explains the mechanisms through which participatory design processes and guideline implementation tools support guideline adherence in LMICs. After clarifying the scope through development of an initial program theory, we conducted a search for evidence and appraised the relevance, richness, and rigor of the identified studies. After extracting data, analysis of the evidence informed the refinement of the program theory. Results: In Chapter 1, 35 participants took part in qualitative data collection and we found that TDF domains with greatest influence on the thematic findings were environmental context and resources, social influences, beliefs about consequences, and beliefs about capabilities. Health workers reported some deviations were intentional (ex. when guidelines were deemed inadequate for a clinical scenario) and other times they were unintentional (ex. when complex patient presentations make guidelines adherence difficult). Health workers were knowledgeable about guidelines and felt strongly that adherence to them was beneficial, however they also faced barriers to implementing them. Challenges related to environmental context were pervasive, including shortages of staff, supplies, and infrastructure. While health workers described frequent interdisciplinary consultation within their teams, strict professional roles and team dynamics sometimes delayed diagnosis and treatment. In Chapter 2, we involved 34 participants in a co-design process to develop and pilot test the TeAMS Toolkit. First, health workers decided that the challenge they would address was that reliance on nutritionists to handle critical tasks sometimes delays guideline adherent care for children with severe malnutrition. They then came to consensus on a strategy that would clarify team member roles in providing care to children with malnutrition and summarize information from guidelines to support performance of those roles. The TeAMS Toolkit was developed to meet these requirements, with iterations based on feedback from health workers. After launching and piloting, we found the TeAMS Toolkit to have good usability (median 77.5, IQR 67.5-87.5). Participants described the Toolkit as easy to use and a helpful reference to look to when delivering care. While there were no significant changes identified in quantitative measures of perceived competence or frequency of task completion, qualitative findings described non-nutritionists feeling able to take on feeding tasks utilizing the Toolkit content to guide them. Participants descried improved collaboration and multidisciplinary teamwork to ensure timely care, which aligned with significant changes (p<0.05) on two out of six measures of teamwork perceptions. In Chapter 3, an initial program theory was developed that included ten context-strategy-mechanism-outcome (CSMO) configurations. Our search identified 10,883 records, and after de-duplication title and abstract screening of 8,697 records was completed. The full text of 112 articles were reviewed and data was extracted from 27 included studies. The extracted data was analyzed and synthesized to refine the initial program theory, resulting in a refined theory with eight CSMO configurations. This theory explicates how participatory processes can contribute to improved health worker engagement, acceptability of guideline implementation tools, group consensus regarding operationalization plans, and teamwork perceptions. In addition, it describes how specific types of guideline implementation tools (descriptions of roles, teamwork skills, job aids, documentation tools) may impact guideline adherence through mechanisms including improved role clarity, visible reminders, gains in competence, and improved efficiency. Conclusion: This dissertation contributes to deepening our understanding of how and why implementation strategies can support guideline adherence in LMICs. Our findings highlight how team collaboration and professional roles impact guideline adherence and describe an implementation strategy that addresses these drivers to improve guideline adherence. We plan to build on this work with further refinement and scale-up of the TeAMS Toolkit. Moreover, the refined program theory we developed can be utilized to guide the selection and design of implementation strategies, ensuring better alignment to context and the best chance of improving guideline adherence.
Exploring the Multilevel Factors and Experiences to Palliative Care Referrals in Patients with Advanced Ovarian Cancer
(2024-10-16) Cho, Su Sie; Berry, Donna
Background. Ovarian cancer presents significant challenges as patients experience high symptom burden and recurrence rates despite advancements in treatment. Integrating palliative care (PC) into the care of patients with advanced ovarian cancer remains critical yet underutilized. Through a scoping review and subsequent empiric research, this dissertation aimed to elucidate the multifaceted factors influencing PC referral practices and patients' lived experiences. Method 1. The first part of the study was a scoping review which involved a comprehensive search across academic databases and journal archives from 2012 to 2023, targeting studies on advanced ovarian cancer and palliative care referral. Key terms such as 'palliative care' and 'ovarian cancer,' alongside additional terms were utilized for inclusivity. Disagreements were resolved through consensus using Rayyan and Covidence platforms, with data extraction employing a descriptive qualitative approach. Method 2. This secondary data analysis investigated patient-reported symptoms, quality of life (QOL), and palliative care (PC) referral data in women with advanced ovarian cancer within the electronic Self-Assessment and Care (eSAC) study conducted at the Gynecologic Oncology clinic at the University of Washington, Montlake campus, between September 2020 and February 2022. Data included demographic characteristics, pain intensity numerical score (PINS), and the EORTC Quality of Life Questionnaire Core 15 Palliative Care (QLQ-C15 PAL). PC referral recommendations were triggered based on specific symptom and quality of life scores. Statistical analyses, encompassing descriptive statistics and logistic regression models, explored associations between patient-reported outcomes (PROs), demographic characteristics, and the likelihood of having a PC referral order. Method 3. This qualitative study examined the lived experiences of women with advanced ovarian cancer in integrating palliative care (PC) into their care using a phenomenological approach. Participants were recruited from the electronic Self-report Assessment and Care (eSAC) study at the University of Washington. Eligible participants had stage III/IV or recurrent ovarian cancer and had triggered a PC referral recommendation within the eSAC study. Telephone interviews were conducted, and data analysis followed Braun and Clarke's six-phase process, leading to a thematic understanding of their narratives. Results 1. This scoping review analyzed 13 studies revealing socioecological factors impacting PC referrals across various socioecological levels. The findings emphasized the significance of patient-specific medical conditions, particularly in ovarian cancer cases. Also, the findings underscored the importance of a comprehensive assessment of physical and psychosocial symptoms to facilitate PC referrals. Results 2. Fatigue and appetite loss were significantly greater in the group receiving a PC referral. Significant differential effects on the likelihood of PC referral across demographic subgroups were examined with several PROs. First, the likelihood of having a PC referral order with appetite loss was higher for participants in a relationship. Second, there was a significant interaction between educational status and insomnia, meaning insomnia had a different impact on the likelihood of having a PC referral order depending on the participants’ educational status. Lastly, a significant interaction was observed between QoL score and participants’ relationship status. Specifically, participants with better QoL and in a relationship status were less likely to have a PC referral order. Results 3. Participants described diagnostic and treatment events unfolding rapidly. Misunderstandings about PC's role, often conflated with hospice care, hindered acceptance. Concerns about time constraints, care coordination, and symptom management also affected readiness to engage with PC services. Conclusion. The findings of these studies emphasize the urgent need to revamp palliative care (PC) referral practices for advanced ovarian cancer patients. The results highlight the complex factors influencing PC referrals, stressing the importance of comprehensive symptom assessment and consideration of non-clinical determinants. As treatment options evolve, identifying reliable factors guiding PC referrals becomes crucial. A holistic approach is advocated to better understand patients' treatment trajectories and acknowledge the interplay of demographic factors in PRO presentation and associations with the likelihood of receiving a PC referral order. Despite some progress, patient acceptance of, and engagement with, PC remains lacking, necessitating improved communication strategies and interventions to clarify the role of PC. Collaborative efforts among stakeholders are essential for realizing patient-centered and integrated PC delivery within oncology settings.
The Cultural Adaptation and Pilot Feasibility Testing of Helping Her Heal (HHH), an Educational Counseling Intervention for Spouse Caregivers of Women with Breast Cancer in Ghana
(2024-09-09) Osei-Assibey, Brenda Adei; Lewis, Frances M
Background. Breast cancer is the leading cancer in Ghana and accounts for 31.8% of cancers in women. In partnered relationships spouses are the primary caregivers and assist wives experiencing breast cancer with activities of daily living, supporting their wives financially and emotionally. Caregiving places burden and strain on spouses. Spouse caregivers are known to have anxiety, depressed mood and sometimes have higher levels of depressed mood than wives. There is therefore a need for an intervention to help spouse caregivers cope better with their wives’ breast cancer and caregiving.Purpose. The overall purpose of this dissertation is to advance the science in spouse caregiving of women with breast cancer in Ghana. In Study 1 (Chapter 2), a three-phase approach and the Ecological Validity Framework (EVF) was employed to culturally adapt Helping Her Heal (HHH), an educational counseling intervention for spouse caregivers of women with breast cancer. The purpose of Study 2 (Chapter 3) was to conduct a field test to assess the appropriateness of the adapted draft HHH-Ghana. The purpose of Study 3 (Chapter 4) was to conduct a pilot study to ascertain the feasibility and short-term impact of the adapted HHH-Ghana. Methods. Both qualitative and quantitative research approaches were utilized in this dissertation. Spouse caregivers were included in all three studies if they could speak and read English, living with their wives or partners for at least 6 months and if their wives had Stages I, II or III breast cancer. Participants from Studies 1 and 2 were the same. In Studies 1 and 2, a single occasion in-depth interview was used to elicit feedback on the intervention manuals from breast cancer nurses and spouse caregivers. The interviews were audio recorded and transcribed verbatim. Both deductive and inductive content analysis were carried out in analyzing the interview data from Study 1. Deductive analysis was conducted for Study 2, a single group pre-post design was employed in Study 3 to ascertain the feasibility and short-term impact of the adapted HHH-Ghana. Five standardized instruments (STAI-Y, CES-D, MIS, CASE and Spouse Skills Checklist) were used to measure the outcome variables of interest. The Wilcoxon Signed Ranked Test was used to assess the short-term impact of the intervention in spouse caregivers of women with breast cancer in Ghana. Exit interviews were conducted with participants at the end of Study 3 to assess what spouse caregivers thought they had gained by participating in the study. Results. Studies 1 and 2 included two breast cancer nurses and four spouse caregivers. Fourteen spouse caregivers participated in Study 2. In Study 1, participants found the intervention to be acceptable and understandable but recommended some changes to be made. A spouse participant said he perfectly understood all the tasks and assignments in the intervention manual while another suggested the inclusion of faith-based activities as a strategy to unwind. In Study 2, participants said the adapted draft HHH-Ghana reflected their feedback and was relevant. A spouse indicated that the adapted draft intervention was relevant because writing a letter to their wives as a way of appreciating them had been modified to verbally expressing appreciation for their wives because it was not in the Ghanaian culture to write letters to their partners. Study 3 showed that the intervention was feasible as recruitment strategies were adequate in enrolling participants, the retention was 87.5% and spouse participants engaged actively in intervention sessions by responding to questions, providing answers, and completing at home assignments with wives. Significant results were achieved in all the outcome variables except one. There was significant improvement in anxiety, depressed mood, spouse self-efficacy, self-care skills and communication. The measure for communication among the couple (MIS) did not record significant change but communication did not get worse. This finding was contrary to the report from the interview data where participants indicated that they were communicating better because of participating in the study. Conclusion. The three-phase approach and the EVF were useful in culturally adapting the HHH. Participants from Study 1 and 2 found the HHH to be acceptable and understandable and made suggestions for change to make it more acceptable and relevant to spouse caregivers of women with breast cancer in Ghana. Study 3 showed that the HHH was feasible and improved anxiety, depressed mood, self-efficacy, and spouse skills in taking care of themselves and their wives. A larger clinical trial can be conducted to ascertain the efficacy of HHH in spouse caregivers of women with breast cancer in Ghana. The HHH-Ghana can be implemented and evaluated at the breast unit of the Korle-Bu Teaching Hospital where the study was conducted. Results from this evaluation will inform policy making regarding the inclusion of HHH in the usual care of women with breast cancer.
Sleep Health Among a Cohort of Nursing Workforce
(2024-09-09) Rejto, Natalie; Walsh, Elaine
Background: The nursing workforce and the care they provide are essential to the health of individuals, families, communities, and populations. Approximately half of nurses report unhealthy sleep, which includes inadequate sleep duration, difficulty falling or staying asleep, short sleep duration, and inconsistent timing of sleep. Poor sleep health among the nursing workforce is associated with adverse health outcomes in the nurse, job turnover, and a decrease in safe and effective nursing care. National research priorities have underscored the need to examine sleep health among nursing workforces to inform effective mitigation strategies and best practices to optimize nursing sleep health and the provision of 24-hour safe, quality nursing care. Purpose: The purpose of this study was to examine the association between job characteristics and sleep health (sleep duration insomnia symptoms, chronotype, self-reported snoring, and daytime dysfunction) across demographic characteristics, care settings and specialties, and sleep hygiene behaviors among a national cohort of registered nurses practicing in the United States and Canada. The specific aims were to: 1) Describe multidimensional sleep health across demographic characteristics (race, ethnicity, and immigration status) among registered nurses, 2) Describe the association between multidimensional sleep health and job characteristics (shift type, shift length, hours worked/week, and practice setting/specialty) among registered nurses, and 3) Test whether individual sleep hygiene behaviors (regularity of falling asleep with light on, brightness of ambient light during sleep, and blue light blocking application installed on electronic device) were effective at mitigating the association between job characteristics and sleep health among registered nurses. Methods: The current study leveraged a subset of the existing national cohort data set of the Nurses’ Health Study 3 (N = 1,342) to conduct three quantitative cross-sectional analyses. The first analysis (Paper one) consisted of a chi-squared test of independence to assess multidimensional sleep health across demographic characteristics of race, ethnicity, and immigration status among nurses. Paper two involved multiple logistic regression analyses to estimate the association between multidimensional sleep health and job characteristics across nursing care settings and specialties. In paper three, logistic regression analysis was used to test for the modifying effect of sleep hygiene behaviors when examining the association between nursing job characteristics and sleep health among nurses practicing in various care settings and specialties. Results: The first study analysis found that nearly 50% of the sample reported a healthy sleep duration on workdays, and more than 75% reported a healthy sleep duration on workfree days. The second analysis results indicated that working more than or equal to 12-hour shifts was not associated with decreased odds of healthy sleep compared to those working less than 12-hour shifts. The third analysis results demonstrated that individual sleep hygiene behaviors did not mitigate the decreased odds of healthy sleep associated with job characteristics. Conclusion: The results from the three dissertation analyses provide important insights that broaden the scientific understanding of sleep health on workdays and workfree days and the complexities of the association with job characteristics among nursing workforces. Programs and policies aimed at improving sleep health among nurses should be extended beyond individual sleep health behaviors and be tailored to the distinct job design in nursing specialties. Future research is needed to expand the conceptualization of nursing work factors and how they influence sleep health among nurses and the associated patient populations.
Identifying the Barriers and Facilitators to Complete Revaccination in Adult Hematopoietic Stem Cell Transplant Survivors in the United States
(2024-09-09) Wickline, Mihkaila Maurine; Berry, Donna L
Background: Comprehensive hematopoietic stem cell transplant (HSCT) survivorship care includes revaccination after transplant to restore immunity to vaccine-preventable diseases (VPDs). Revaccination after HSCT to restore VPD immunity is a complex undertaking for HSCT survivors, and current revaccination uptake is sub-optimal. As HSCT survivors are at higher risk for morbidity and mortality from infectious causes, efforts to reduce infectious risk in this population, such as improving the rate of fully revaccinated survivors, are imperative. No existing published studies have reported comprehensive barriers and facilitators to complete revaccination among adult HSCT survivors in the US. Purpose: The overall objective of this dissertation is to advance understanding of the factors influencing revaccination uptake among adult HSCT survivors living in the US. This dissertation had three specific aims: 1a) Determine the prevalence of adult HSCT survivors who are completely, partially, or not revaccinated 2-8 years after HSCT using a well-characterized and geographically diverse sample, 1b) Examine associations between demographic variables, social determinants of health, clinical variables, past vaccine behaviors, vaccine hesitancy (Vaccine Confidence Scale), and revaccination status in adult HSCT survivors, 2) Explore vaccine hesitancy in the context of revaccination among adult HSCT survivors by describing the level of agreement between quantitative results of vaccine hesitancy (Vaccination Confidence Scale) and qualitative results (open-ended survey items regarding vaccine confidence), and 3) Identify barriers and facilitators to complete revaccination using fixed and open-ended responses and describe the extent to which these factors explain the three revaccination status categories (completely, partially, or not revaccinated) among adult HSCT survivors. Methods: This dissertation comprised one quantitative analysis and two convergent mixed methods analyses of a cross-sectional revaccination survey of adult HSCT survivors between 2-8 years after transplant and living in the US. The survey was sent to eligible survivors in the Fred Hutchinson Cancer Center (FHCC) Long-term Follow-up (LTFU) research cohort. The first analysis (quantitative, n=338) determined the point prevalence of revaccination outcomes with descriptive statistics and examined associations between revaccination outcomes and predictors using logistic regression. The second analysis (quantitative, n=332 and qualitative, n=189) determined the point prevalence of vaccine confidence, examined relationships between vaccine confidence levels and revaccination outcomes and intent to complete revaccination using the Fisher’s exact test, and associations between vaccine confidence levels and predictors using logistic regression. Additionally, open-ended responses related to benefits, trust, and harms (the constructs of the Vaccine Confidence Scale) were analyzed using inductive thematic analysis. Lastly, a merged analysis to compare quantitative and qualitative findings was completed. The third analysis (quantitative and qualitative=194) determined the prevalence of barriers and facilitators using descriptive statistics, examined the association between the number of barriers and facilitators and revaccination outcome using logistic regression, and tested relationships between the most frequent specific barriers and facilitators and revaccination using the Fisher’s exact test. Additionally, open-ended responses were analyzed using deductive content analysis using the WHO behavioural and social drivers of vaccination framework. Finally, a merged analysis was conducted to compare quantitative and qualitative findings. Results: In the first analysis, the point prevalence of revaccination outcomes was 62% completely revaccinated, 33% partially revaccinated, and 4% not revaccinated. Factors associated with incomplete revaccination were shorter time from transplant, inadequate immune reconstitution, and not having received all childhood vaccines as a child. In the second analysis, the point prevalence of vaccine confidence was 69% high confidence, 20% medium confidence, and 11% low confidence. Revaccination outcomes and intent to revaccinate were significantly different across vaccine confidence levels. Factors associated with high vaccine confidence included: living in a zip code that voted for the Democratic presidential candidate in 2020, having means to pay out-of-pocket or health insurance coverage for vaccines, receiving all pre-HSCT adult vaccines, and receiving all the recommended COVID-19 vaccines. Themes were categorized as 1) Physical and mental benefits and beliefs about benefits (Benefits); 2) Existing factors for trust, prerequisites for trust, and impeding factors to trust (Trust); 3) Vaccine quantity, vaccine side effects, vaccines and harm, and not all vaccines are the same (Harms); and 4) Uniqueness of HSCT vaccinees and revaccination motivation and behavior (Other). The merged analysis showed congruence between Vaccine Confidence Scale scores and overall vaccine confidence coding from open-ended responses. Finally, the merged analysis created a narrative about the relative importance of the constructs when approaching revaccination by vaccine confidence level: the low confidence group relayed (dis)trust>harm>benefits, the medium confidence group relayed trust>benefits~harm, and the high confidence group relayed benefits>trust>harm. In the third analysis, the most frequent barriers were the inability to receive live vaccines because of continued immunosuppression, finding a place in the community that would give childhood vaccines to adults, and delayed immune system recovery. The most frequent facilitators were having healthcare insurance covering vaccines and having a clear calendar of what vaccines to receive and when. Further, with each additional reported barrier, the odds of being completely revaccinated were lower, OR=0.58 (95% CI 0.459-0.722), and with each additional reported facilitator, the odds of being completely revaccinated were higher, OR=1.31 (95% CI 1.05-1.63), p <0.001. Two of the five most reported barriers were significantly associated with no or partial revaccination: taking immunosuppressive therapy so not eligible for live vaccines (p= 0.001) and immune system not recovered enough for vaccines (p <0.001). Three of the five most reported facilitators were significantly associated with being fully revaccinated: having a clear calendar of what vaccines to get when (p= 0.032), being able to contact LTFU for vaccine questions (p= 0.018), and getting vaccines at FHCC (p= 0.041). Content analysis suggested that most barriers were in the “practical issues” construct, especially service quality and availability. A surprising, but important theme was the transplant center as vaccination site, with 15% of all respondents commenting in free text that they believed that is where revaccination should be offered. The merged analysis mostly indicated convergence. Overall, the barriers seemed to outweigh the facilitators as influencing factors in the no and partial revaccination groups. Conversely, the facilitators seemed to outweigh the barriers as influencing factors in the complete revaccination group. Discussion: As few factors were associated with revaccination outcomes, interventions to increase revaccination uptake do not need to be targeted to certain survivors. Since many survivors cannot be revaccinated promptly due to delayed immune recovery, clinicians must extend the period to evaluate for revaccination readiness and ensure eventual revaccination. We can no longer ignore that HSCT survivors experience vaccine hesitancy and that vaccine hesitant HSCT survivors are less likely to complete revaccination. We must develop population-specific interventions to help vaccine-hesitant survivors choose to revaccinate. Reducing barriers and enhancing facilitators associated with poor revaccination outcomes is required. Clinicians can assess patients for barriers and facilitators and formulate individual plans towards complete revaccination. Novel programs for reducing system barriers, such as a vaccine clinic co-located within the HSCT survivorship clinic, should be designed and tested. Conclusions: In these studies, revaccination outcomes were associated with few factors, only 69% of survivors had high vaccine confidence which significantly affected revaccination intent and outcome, and practical barriers and facilitators played a consequential role in revaccination uptake. Taken together, these findings significantly expand our knowledge of the factors influencing revaccination uptake among US HSCT survivors. Future research that builds on these findings should focus on prospective methods and intervention testing.

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