Judith A. Berg

PHYSICAL ACTIVITY: PERSPECTIVES OF MEXICAN AMERICAN AND ANGLO AMERICAN MIDLIFE WOMEN

Despite the well-known health benefits of physical activity (PA), most midlife and older adults lead sedentary lifestyles. Anglo American women and Mexican Americans of both genders are two of the least physically active groups. We conducted three focus groups to identify attitudes and beliefs about PA among Mexican American and Anglo American midlife women. Our long-term goal was to identify culture-specific interventions that promote long-term PA continuation. Significant differences were found between the two groups. While Anglo American women valued individual outcomes, and spoke of personal factors promoting or preventing exercise, Mexican American women viewed PA as prescriptive, important for restoring health, and cited family responsibilities and family attitudes as factors that promoted or prevented them from exercising. We found that in order for PA interventions to be successful in each group, they must be tailored to the values of each cultural group.

GAINING ACCESS TO UNDERRESEARCHED POPULATIONS IN WOMEN'S HEALTH RESEARCH

Culture is an important variable in womens health research, and sample selection must include plans to recruit participants who represent the overall cultural makeup of the population. However, gaining access to underresearched groups is a major challenge and requires specific planning. Salient access techniques utilized by epidemiological researchers include (a) obtaining the support and endorsement of community leaders, (b) advertising the research in community publications, and (c) utilizing age, gender, and culturally matched research assistants. Although these elements were included in the planning of a study of the perimenopausal transition of Filipino American midlife women, the more powerful attractors for this particular cultural group were their pride in participating in a study that was associated with a major university and their intense community service orientation. Since each cultural group has unique issues and concerns, researchers must familiarize themselves with the values of their target group and emphasize these in recruitment approaches.

Information sources, menopause beliefs, and health complaints of midlife Filipinas.

Although the perimenopausal transition is a universal experience for women who live long enough, its cross-cultural variations have been explored only recently. In this study, we investigated some of the expectations and health beliefs of 165 midlife Filipina Americans using focus groups and a short-answer questionnaire. Participants reported on (a) how they learned about menopause, (b) who they talked to about menopause symptoms or issues, (c) how Filipino women and men feel about menopause, and (d) the most common health complaints of midlife Filipinas. Findings revealed that midlife Filipina Americans primarily obtain their information from and talk about menopause with female relatives and friends. They usually viewed menopause as a normal life phase, yet knew less about how Filipino men feel about menopause. Health complaints of midlife Filipinas were mainly estrogen-related menopause symptoms and negative affect symptoms.

Where we are today: prioritizing women's health services and health policy. A report by the Women's Health Expert Panel of the American Academy of Nursing.

There has been a recent resurgence of interest in womens health as evidenced by several federal and international policy-shaping reports that will impact womens health services. These reports include the 2010 Affordable Care Act, the formation of the National Prevention Council and Strategy, the 2011 IOM report on clinical preventives services for women, and the World Health Organization strategic plan for 2010-2015. In this paper, we summarize and discuss these reports and discuss implications of enacting the suggested health policies. We highlight policy strategies and recommendations that will extend national and global recommendations to improve womens health and wellness across the lifespan and emphasize the urgent need for preventive services. We conclude this paper by detailing our broad recommendations for putting prevention into practice illustrated by specific recommendations related to unintended pregnancy prevention and management.

Menopausal symptom perception and severity: results from a screening questionnaire

BACKGROUND Although it is widely acknowledged women experience symptoms during their transition from reproductive to postreproductive stage, there is inconsistency as to the prevalence of symptoms as well as their severity ratings. AIM AND OBJECTIVES The purpose of this study was to describe symptom perception and severity in mid-life women volunteering for an intervention study for menopause symptom management. DESIGN A cross-sectional descriptive design was used to provide data on presenting symptoms in a sample of women negotiating the menopausal transition. METHODS A community-based sample of Caucasian women aged 43-55 years was recruited from national nursing media, local media and a variety of local community sources. A screening questionnaire was administered to determine qualification for study entry based upon symptom severity scores from the questionnaire. This report includes results from the screening questionnaire. RESULTS One hundred and sixty-five women were screened to obtain 110 qualified participants with mean age of 49.3 SD 3.04 years who were 4.7 SD 7 months past their last menstrual period. Sleep difficulties, forgetfulness and irritability were perceived by the highest number of women while sleep difficulties, night sweats, irritability and forgetfulness were rated the most severe. CONCLUSIONS Findings from this study expand understanding of the menopause symptom experience, because few reports include symptom severity reports. All aspects of the symptom experience are necessary to develop appropriate interventions and to evaluate them. RELEVANCE TO CLINICAL PRACTICE Providing education about menopause symptoms is central to nursing practice of mid-life women. Therefore, nurses must keep abreast of current knowledge to prepare women for their transition to postreproductive phase or to reassure women who are surprised to find hot flashes are not the only symptoms encountered.

A mindful eating intervention: A theory-guided randomized anti-obesity feasibility study with adolescent Latino females

UNLABELLED While pediatric anti-obesity lifestyle interventions have received considerable attention, few show sustained impact on body mass index (BMI). Using the Information-Motivation-Behavioral Skills Theory as a framework, we examined the effects of a satiety-focused mindful eating intervention (MEI) on BMI, weight and mindful awareness. METHOD DESIGN AND SETTING Utilizing a two-group, repeated measures design, 37 adolescent females with a BMI >90th percentile, recruited from a public high school in a Latino community in the Southwestern United States, were randomized 2:1, one third to the group receiving a 6-week MEI and two thirds to the comparison group (CG) receiving the usual care (nutrition and exercise information). INTERVENTION During six weekly 90-min after school MEI group sessions, the behavioral skills of slow intentional eating were practiced with foci on satiety cues and triggers to overeat. OUTCOMES Feasibility and acceptability were measured as participant retention (goal ≥55%) and evaluative comments from those in the MEI group, respectively. BMI and mindful awareness were measured on site at baseline, immediately post intervention, and at 4-week follow-up (week 10). RESULTS Fifty-seven and 65% of those in the MEI and CG were retained throughout the study, respectively. MEI participants showed significantly lowered BMI compared with CG participants, whose weight increased (p<0.001). At six weeks, the MEI group BMI decreased by 1.1kg/m(2) (BMI continued to decline to 1.4kg/m(2) by week 10); while CG BMI increased by 0.7kg/m(2) (consistent with BMI >90th percentile standard growth projections). CONCLUSIONS Initial and sustained decline of BMI in the MEI group supports further study of this theory-guided approach, and the value of practicing satiety-focused mindful eating behavioral skills to facilitate health behavior change.

Breaking down silos: The future of sexual and reproductive health care—An opinion from the women's health expert panel of the American Academy of Nursing

The traditional model of healthcare delivery in the United States has been to provide sexual and reproductive health (SRH) care as a separate service in private settings, in clinics, such as Planned Parenthood, and in underfunded community health centers and public health departments (Auerbach et al., 2012). Deemed too fragmented, the more contemporary approach is to integrate SRH into primary care specialties. However, there is concern among women’s health leaders about the adequacy of SRH preparation for nurse practitioners (NPs) educated in primary care specialties, such as Family, Adult/Gerontology, and Pediatrics. This editorial highlights our concerns about SRH content for women and men in NP primary care curricula and outlines the steps that need to be taken to assure competency of primary care NPs to care for the SRH needs of the population. Previously thought of as maternal and child health care, contemporary opinion is that SRH should be available and accessible for all men and women, including ethnic and sexual minorities, throughout their life span (World Health Organization [WHO], 2009). This expanded view includes preconception care, sex education, contraception, pregnancy and unplanned pregnancy care, gynecological and other women’s health care, genitourinary conditions of men, infertility, sexual health promotion, and care coordination with public health and other primary care services (Auerbach et al., 2012). We support the WHO’s recommendation that SRH be integrated into existing primary care in ways that reduce barriers to access (WHO, 2011). This healthcare delivery model is utilized extensively and successfully in the United Kingdom (Royal College of Nursing, 2009). Of concern, however, is whether or not primary care education for NPs in the United States includes sufficient content to prepare these primary care providers to assume the full array of SRH care. Implementation of the Patient Protection and Affordable Care Act 2010 is predicted to strain healthcare delivery resources, in that persons currently without health insurance will have access to health insurance on healthcare exchanges and care may be provided through accountable care organizations. In addition, the total number of adults of reproductive age (18–44) in the United States is expected to increase from 112 million to 125 million by 2025. SRH services will surely need to increase proportionately. NPs are central to SRH care in this country; however, a number of workforce changes threaten the supply of NPs appropriately educated and trained to provide these services (Auerbach et al., 2012). For example, the RAND study (Auerbach et al., 2012) identified a reduction in programs that prepare Women’s Health NPs. Instead, the preponderance of programs prepares NPs in the primary care specialties already specified. Although recent forecasts by Auerbach et al. (2012) predict a large growth in the supply of NPs, most will be educated in primary care specialties. This then begs the question as to whether or not these NPs will be adequately prepared to meet the SRH needs of the burgeoning patient population. It is no longer feasible or desirable to provide SRH care in a fragmented fashion that necessitates women and men seeing multiple providers. With the projected growth in NPs educated in primary care, we need to redouble our efforts to insure they are adequately prepared to meet the increasing demands for SRH care in primary care settings. It has been well established there is a direct relationship between safe and quality care and a nurse’s education and training (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Further, the ever-changing evidencebased science and clinical understanding of SRH demands that we must be careful not to throw the baby out with the bath water. Hence, discontinuing Women’s Health NP programs and courses (Auerbach et al., 2012), and limiting SRH content to NP primary care focused curricula is certainly a serious concern. It is critical that nurses and particularly educators in NP primary care specialties carefully look at the following:

Symptom responses of midlife Filipina Americans.

OBJECTIVE The purpose of this study was to describe the perimenopausal symptom responses of Filipino American midlife women. DESIGN This cross-sectional, descriptive survey collected symptom response information on Filipino American midlife women aged 35 to 56 years (n = 165) who self-identified as Filipina American and were proficient in the English language. Women were recruited from community churches and social groups. A survey questionnaire comprised of health history questions and a symptom checklist with symptom response questions were completed by the participants. RESULTS The symptom responses of women were compared by age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phases of premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). Indications from chi 2 tests showed that women in the 35-to-39- and 50-to-56-year groups were more likely to take acetaminophen (Tylenol) or aspirin for symptoms, and women in the 45-to-49- and 50-to-56-year groups were more likely to be on hormone replacement therapy. Surprisingly, women in the 50-to-56-year group were less likely to use talking with friends as a symptom management strategy. CONCLUSIONS Nonpharmacologic symptom management strategies exceeded the use of medications (hormones, over-the-counter) by Filipina Americans. This may be a strong indicator of their positive attitude toward this phase in their life and sends a message to clinicians about the choices that these women make for symptom management. Culturally relevant care would include alternatives to hormone replacement therapy in education materials about the perimenopausal transition for midlife Filipinas.

Multiple publications from a single study: Ethical dilemmas

Editors, editorial board members, volunteer reviewers, and authors all have stakeholder responsibilities for ensuring that published material conforms to established ethical principles of scientific conduct. Following ethical practices assures a discipline’s scientific integrity. As a member of the Committee of Publication Ethics (COPE), JAANP follows the COPE Code of Conduct (www.publicationethics.org) for best practices in publishing manuscripts, investigating suspected cases of redundant (duplicate publication or “salami slicing”), investigating suspected plagiarism, identifying fabricated data, and resolving conflicts of interest. Furthermore, Sections 1.09 and 1.10 of the current sixth edition of the American Psychological Association (APA) publication manual directly align with COPE’s intent (APA, 2010, pp. 13–16). Authors considering manuscript submission to JAANP should be familiar with COPE guidelines and the APA style guide. There are ongoing ethical issues about publishing multiple manuscripts obtained from a single source. The international debate on these issues is not limited to a single discipline; a recent web search found numerous journals representing a breadth of disciplines have discussed the issue with many addressing the topic more than a decade ago. While on the surface it appears that obtaining multiple manuscripts from a project is discouraged, depending on the size and scope of the project, there can be legitimate reasons authors choose to publish more than once (Grimmer, 2005; Karlsson & Beaufils, 2013). Rather than rehash and present the negative aspects of redundant publication, we hope to present information that contrasts the wrong way to approach such activities with an approach that maintains the ethical integrity of all stakeholders. To achieve our goal, we will first highlight some of the issues and problems commonly associated with the practice. Then we will turn to an approach that should alleviate concerns while demonstrating some of the “best practices” that authors should consider when developing projects and disseminating findings.

Recognition, Regulation, Scope of Practice: Nurse Practitioners’ Growing Pains

The Nurse Practitioner (NP) role began in the United States in Colorado when Henry K. Silver, M.D. and Loretta C. Ford, R.N., EdD, FAAN, FAANP developed a program to educate nurses for primary care of children and expand and improve the role of the nurse at the University of Colorado (Silver, Ford, Ripley & Igoe, 1985). In fewer than 10 years, 65 NP programs were established in pediatrics alone while other programs focused on women’s health (Wilson, 1994). These early programs educated more than 1000 NPs who worked in a variety of settings and aimed to decrease the health care manpower shortage and improve access to health care particularly in rural areas. Since there were few practicing NPs in those early years, NP students were taught and precepted primarily by physicians, and this led to controversy about the role within nursing. This special edition of the Journal of the American Academy of Nurse Practitioners highlights the current experiences of NPs in international settings, and this will likely stimulate feelings of déjà vu to those of us who lived through similar issues here in the US. I experienced the controversy in the early days, because my clinical practice as a women’s health NP began in the mid-1970s. My colleagues who had gone on to academic careers questioned my commitment to nursing and to nursing values. A common question was “Are you a nurse, or are you a mini-doc?” My answer was, is, and will always be: “I am a nurse with primary care skills. I take care of my patients within a nursing framework. My approach to all health care is via a health promotion, disease prevention, and risk reduction framework which is consistent with the philosophy of the nursing profession.” This was startling to many colleagues, but decreasingly so. Colleagues today are less distrusting of the NP role and increasingly accepting that my values lie in nursing, not in the medical model. I care for my patients as a fully prepared, primary care provider of women. My population happens to be women, but I have thousands of colleagues who care for families, adults, children, acute care patients, etc. Following the early years came decades of turmoil, agitation, turf battles, and developmental dilemmas in this profession I so love. Name recognition was a number one issue. What is a NP? I remember being on a trip to China when the doors to the west were newly opened in 1981. My husband and I were with an organized group of professionals who did not even recognize what a NP was. Several asked questions like, “Are you a nurse’s aid? Are you a practical nurse?” I answered, “I am a professional nurse with RN, BSN, and MSN credentials. I am qualified to provide primary care to women, and I do many things that licensed physicians in women’s health do.” This was met with astonishment, incredulity, and uncertainty. But, by the end of the trip (during which I was asked to advise several women with health issues), I was accepted as a highly skilled professional with appropriate credentials to do the work that I love to do. Over the decades, NPs in the United States have struggled with issues related to licensing and certification, recognition (by other health professionals, by funding bodies—which has led to reimbursement problems—and by patients), scope of practice dilemmas, physician collaboration, and of course, educational preparation (Wilson, 1994; Brush & Capezuti, 1996; Garland & Marchione, 1997; Taylor-Seehafer, 1998; Pearson, 1999). All of these aspects of professional development must be carefully dealt with. And over the years, NPs in the US have done so. It has primarily been our professional organizations, of which the American Academy of Nurse Practitioners is one, that have fought our battles, celebrated our successes, and pointed out the next areas we should focus on. Our current status, detailed by Phillips (2010) and forecasted by Towers, Dempster and Counts (2003), suggests there is still work to do. Not all states in the US afford NPs the rights to full prescriptive authority, autonomous practice, and freedom from physician supervision. But, we have made significant progress in these arenas, and our successes have potential to assist our international colleagues who have not reached our level of sophistication. This special issue of the Journal of the American Academy of Nurse Practitioners is devoted to the growth and development of the NP role in international settings. We believe this collection of papers will reflect our past while focusing us on our future trials and tribulations. Just because we experienced growing pains, does not mean the pain is behind us. In fact, these papers can serve to remind us to “garner our forces” for battles yet to come. In the paper by Nasaif, primary care physicians in Bahrain were studied before and after an educational intervention to discern their knowledge and attitudes