Elnora P. Mendias

A comparative analysis of the changes in nursing practice related to health sector reform in five countries of the Americas

OBJECTIVE To identify changes in nursing practice and the nursing-practice environment that have occurred with implementation of health sector reform in five countries in the Americas. METHODS An exploratory study of selected settings in Argentina, Brazil, Colombia, Mexico, and the United States of America was conducted between 1997 and 1999 to collect narrative data from 125 professional nurses about their perceptions of nursing practice and changes in work environments. Descriptions of characteristics and trends in nursing practice in the study sites were also obtained. RESULTS Reorganization of health services has occurred in all five of the countries, responding to health sector reform initiatives and affecting nursing practice in each country. Respondents from all five countries mentioned an emphasis on private enterprise, changes in payment systems for patients and providers, redistributions in the nursing workforce, changes in the personnel mix and nursing-practice functions, work shifting from the hospital to the community, and greater emphasis on cost control and prevention in practice settings. CONCLUSIONS The study provides initial information about current nursing issues that have arisen as a result of health care reform initiatives. Regardless of differences in service models or phases of health sector reform implementation, in all the countries the participating nurses identified many common themes, trends, and changes in nursing practice. The driving forces for change and their intensity have been different in the five countries. Nurses maintain their core values despite increased work stress and greater patient care needs in all the countries as well as economic crises in the Latin American countries.

Reduced breastfeeding rates among obese mothers: a review of contributing factors, clinical considerations and future directions.

Maternal obesity is associated with significantly lower rates of breastfeeding initiation, duration and exclusivity. Increasing rates of obesity among reproductive-age women has prompted the need to carefully examine factors contributing to lower breastfeeding rates in this population. Recent research has demonstrated a significant impact of breastfeeding to reduce the risk of obesity in both mothers and their children. This article presents a review of research literature from three databases covering the years 1995 to 2014 using the search terms of breastfeeding and maternal obesity. We reviewed the existing research on contributing factors to lower breastfeeding rates among obese women, and our findings can guide the development of promising avenues to increase breastfeeding among a vulnerable population. The key findings concerned factors impacting initiation and early breastfeeding, factors impacting later breastfeeding and exclusivity, interventions to increase breastfeeding in obese women, and clinical considerations. The factors impacting early breastfeeding include mechanical factors and delayed onset of lactogenesis II and we have critically analyzed the potential contributors to these factors. The factors impacting later breastfeeding and exclusivity include hormonal imbalances, psychosocial factors, and mammary hypoplasia. Several recent interventions have sought to increase breastfeeding duration in obese women with varying levels of success and we have presented the strengths and weaknesses of these clinical trials. Clinical considerations include specific techniques that have been found to improve breastfeeding incidence and duration in obese women. Many obese women do not obtain the health benefits of exclusive breastfeeding and their children are more likely to also be overweight or obese if they are not breastfed. Further research is needed into the physiological basis for decreased breastfeeding among obese women along with effective interventions supported by rigorous clinical research to advance the care of obese reproductive age women and their children.

Perceptions of Health and Self-Care Learning Needs of Outpatients With HIV/AIDS

Abstract Health promotion increases healthy behaviors, enhances health status, and decreases health care costs of chronically ill persons. As HIV has become a chronic illness, many HIV-positive persons may have health learning needs that affect their behaviors, health status, and health care costs. Health learning needs may be general or HIV specific. Social stigma may affect learning resource usage. We used Penders Health Promotion Model and community-based health promotion principles as theoretical underpinnings for an exploratory study of perceived health and self-care learning needs, barriers, and preferred learning modalities of outpatients with HIV/AIDS. A nonrandom sample of 151 adults completed a researcher-designed self-report survey. Most (97%) expressed interest in health and self-care. Many identified multiple topics, learning barriers, and preferred learning modalities. A statistically significant difference (p = .027) was noted in communication needs of participants diagnosed with HIV versus AIDS. Findings have led to practice changes, health promotion activities, and further research.

Food security, maternal feeding practices and child weight-for-length

BACKGROUND Over consumption of energy-dense nutrient-poor foods may contribute to childhood obesity. We hypothesized that greater than recommended servings of sugar sweetened beverages and foods, indicators of food security, and a high maternal recumbent weight-for-length are positively associated with high percentages of child overweight/obesity. METHODS This secondary data analysis consisted of a sample of 240 mother-child dyads. The original studies were designed to examine the effect of a public health nursing intervention on optimal childhood growth for low-income, minority children. Eligibility to participate included: 1) mothers self-identified as Hispanic; 2) children were 12-24 months old; and 3) children were enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); and 4) children were free of any major disease. Multivariate logistic regression examined the association between child weight, weight-for-length, maternal recumbent weight-for-length, childs eating schedule, maternal attitudes on feeding, food security, and consumption of sugar-sweetened beverages, desserts and fatty meats. RESULTS Receiving SNAP was positively associated with child weight-for-length (WL). Children whose mothers reported ever having received SNAP were 2.01 times more likely to be overweight compared to children whose mothers did not report ever having received SNAP (95% CI=1.04-3.90). Children who consumed desserts were 2.87 times more likely to be overweight compared to children who did not consume desserts (95% CI=1.19-6.88). Also, childs caloric intake was significantly associated with child WL. Children who consumed more calories were 1.00 times more likely to be overweight compared to children who consumed fewer calories (95% CI=1.00-1.00). DISCUSSION Research on food security and childrens weight has reported mixed findings. Methodological issues have been identified as contributory to the inconsistent findings. Of paramount importance to these studies is the measurement of low food security. CONCLUSION Children in this sample who were food insecure, as indicated by SNAP recipients, were more likely to have a higher WL measurement. Future studies should focus on the correlation between food security and hunger/satiety cues.

Early Infant Feeding Influences and Weight of Children

Childhood obesity has become a major health concern in nearly every country in the world. In the United States, the number of overweight children aged 2 to 5 years has more than doubled in the past 30 years. Overweight and obesity, already epidemic among the world’s adults and children in both developed and developing countries, is escalating. While 61% of U.S. adults and almost 12% of U.S. children were overweight in 2001, a decade later, over two thirds of U.S. adults and almost one-third of U.S. children and adolescents were overweight or obese (Satcher, 2011). A 2010 estimate by the World Health Organization (WHO, n.d.[a]) indicated 42 million overweight children under five years of age worldwide, with 35 million living in developing countries. However, 2010 estimates provided by the International Association for the Study of Obesity International Obesity Taskforce (IASO/IOTF, n.d.) indicated one billion overweight (and another nearly half billion obese) adults internationally, with even higher estimates if adjusted for Asian-specific obesity measures. Moreover, the IASO International Obesity Taskforce’s 2010 estimated 200 million obese or overweight school-aged children (IASO/IOTF, n.d.[b]). Global trends toward childhood overweight or obesity have been attributed to two major factors: 1) increasing intake of energy-dense foods, high in sugars and fats and nutrient-poor (low in beneficial nutrients, such as minerals, vitamins, and healthy micronutrients); and 2) increasingly sedentary lifestyles, with low physical activity (Corvalan et al., 2009; Satcher, 2011; WHO, n.d.[b],). However, though primarily associated with unhealthy nutrition and limited physical activity, WHO (n.d.[b]) suggests that increased childhood obesity rates are related to child behaviors and numerous economic or social changes, as well as environmental, educational, urban planning, agricultural, transportation, and food policies. Polhamus et al. (2009) reported that data from 1998−2008 Pediatric Nutrition Surveillance System indicate prevalence of overweight/obese preschool children as 14.7%, and this prevalence is higher among Hispanic preschoolers (18.5%). Infant and toddler stages are a time of transition from dependent feeding to independent feeding. During early life, weight trajectories and food preferences predict trends and preferences throughout life (Allen & Myers, 2008). Early childhood is a crucial stage for monitoring growth and BMI and the most opportune time to prevent obesity in children by promoting healthy dietary and physical activity behaviors (Hawkins & Law, 2006a; He, 2008; Story et al., 2002). Many

Community based participatory research programs in the United States. Foreword.

In our first outing as issue editors for Family & Community Health, we have been astounded by the number, depth, and variety of community-based participatory research (CBPR) programs being conducted in the United States and internationally. CBPR is broadly represented in this issue as research that has its roots in the community and has arisen from issues pertinent to the community. We have chosen articles in which CBPR distinctively engages researchers and community collaborators as equal partners in all facets of research projects.1 CBPR methodology can be used with all populations, but is especially relevant to vulnerable populations, whose vulnerability may be conferred by income status, historical and/or current discrimination, language barriers, educational opportunities and achievement, gender, cultural background, or lifestyle preferences. CBPR is particularly appropriate for these groups because of its emphasis on acknowledging community ownership, equal partnership in the research process, and ethical standards of research conduct. As owners of their communities, community members best know what research is pertinent for their residents and settings. In this issue, several projects serve as models of how to avoid exploitation of vulnerable populations through inclusion of the community in every step of research. Several articles exemplify community ownership. For example, Cummins and colleagues describe how the Apsaálooke (Crow) tribal members of Montana initiated collaboration among local, tribal, and academic partners to address water contamination and population exposure on tribal lands. Peercy and colleagues describe how the Community Readiness Model guides assessment of key community concerns. After an assessment of the Choctaw Nation members’ interest in cardiovascular disease, the authors realized that the community was interested in the effects of methamphetamine usage on cardiovascular disease and developed and presented an educational program featuring this content to more than 20 000 community members. The articles vary by methodology as well. Kelly and colleagues employ a traditional randomized controlled trial to determine the outcomes of a culturally specific violence prevention intervention for elementary school students and their families in a largely Mexican American community. Haque and Rosas integrate photovoice and concept mapping in their study of immigrants’ perceptions of their neighborhoods to create and interpret a conceptual framework illustrating the residents’ priorities for action. Keyser and colleagues use CBPR approaches with Pennsylvanian maternal and child health stakeholders to redesign local systems of care for women and children, illustrating CBPR use as a program planning and evaluation model as well as research methodology. Capacity building through CBPR is portrayed by Downey and colleagues’ description of strategies and processes used in rural Lower Mississippi Delta counties to address nutrition-related chronic diseases. Imaginative approaches to CBPR are also exemplified. For example, Gray and colleagues describe how inclusion of creative expression, such as Native American storytelling and other traditional arts, can result in an “atmosphere of delight” (p. 186), which enhances community learning about health promotion and facilitates better understanding among community partners. McGinnis and colleagues explain their use of a community health development model to identify community health issues, such as child overweight, and to enhance CBPR approaches to community-identified issues through helping community partners receive basic research training. We hope these articles will provide future direction and inspiration to CBPR practitioners and their communities, as well as to other healthcare providers seeking ways to advance the health of vulnerable populations. We especially want to thank our national panel of reviewers whose rigorous critiques and comments assisted us in choosing these articles for publication from the many excellent manuscripts submitted, and Leigh Beshears, our invaluable support staff.