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For many children of color, the cumulative impact of pre-existing stressors, disparities, and pandemic-related losses has contributed to a toxic level of stress. Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health problems. School nurses are the primary health professionals who interact with children daily during the academic year, which positions them to identify risk factors within the social determinants of health that contribute to the development of toxic stress. The Toxic Stress Schema (TSS) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children. A case study approach is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying resources to support the child's physical and mental health., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary., Design and Methods: Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus., Findings: Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce., Conclusions: The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all., Clinical Relevance: The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims., (© 2022 Sigma Theta Tau International.)

Aims: Chlamydia disproportionately affects individuals aged 15-24 years. A lack of chlamydia knowledge in this high-risk group likely contributes to decreased testing, but interventions to increase chlamydia knowledge in this population are not well-described in the literature. The purpose of this pilot project was to increase chlamydia knowledge in a sample of university students using nurse-developed web-based education., Design: A pre- and post-test design was used to evaluate participant knowledge of chlamydia before and after completing a nurse-developed web-based education intervention designed for university students., Methods: Forty-seven undergraduate students at one U.S. university participated. A focus group and scientific evidence informed the development of the web-based education., Results: Participants had a significant increase in chlamydia knowledge after completing the online educational intervention (M = 8.0, SD = 0.000) compared to baseline (M = 6.5, SD = 1.5), t(33) = -5.821, p < .0001. Pilot results provide promising evidence that web-based nurse-developed education designed specifically for university students can increase chlamydia knowledge., (© 2022 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Introduction: The Toxic Stress Schema (TSS) is an ecological framework with a social justice lens for identifying and alleviating stress and strengthening social determinants of health for children and families of color impacted by the COVID-19 pandemic and the cumulative effects of racism and generational, systemic inequities., Method: Relevant literature is reviewed, and examples were provided to illustrate the differential impacts of the "stress superstorm" of 2020 had on children of color based on their family's position on the advantage-disadvantage continuum., Results: The utility of the TSS framework as a model for advanced nursing practice is demonstrated, and recommendations are formulated for the pediatric nurse practitioner's role in health policy., Discussion: The COVID-19 pandemic elucidated the historical inequities experienced by children and families of color. The TSS framework provides a model for recognizing, organizing, and implementing., (Copyright © 2021 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Objective: Group Well-Child Care (GWCC) has been described as providing an opportunity to enhance well-being for vulnerable families experiencing psychosocial challenges. We sought to explore benefits and challenges to the identification and management of psychosocial concerns in Group Well-Child Care (GWCC) with immigrant Latino families., Methods: We conducted a case study of GWCC at an urban academic general pediatric clinic serving predominantly Limited English Proficiency Latino families, combining visit observations, interviews, and surveys with Spanish-speaking mothers participating in GWCC, and interviews with providers delivering GWCC. We used an adapted framework approach to qualitative data analysis., Results: A total of 42 mothers and 9 providers participated in the study; a purposefully selected subset of 17 mothers was interviewed, all providers were interviewed. Mothers and providers identified both benefits and drawbacks to the structure and care processes in GWCC. The longer total visit time facilitated screening and education around psychosocial topics such as postpartum depression but made participation challenging for some families. Providers expressed concerns about the effects of shorter one-on-one time on rapport-building; most mothers did not express similar concerns. Mothers valued the opportunity to make social connections and to learn from the lived experiences of their peers. Discussions about psychosocial topics were seen as valuable but required careful navigation in the group setting, especially when fathers were present., Conclusions: Participants identified unique benefits and barriers to addressing psychosocial topics in GWCC. Future research should explore the effects of GWCC on psychosocial disclosures and examine ways to enhance benefits while addressing the challenges identified., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Importance: Long-term effectiveness of a peer-led asthma self-management program in improving asthma outcomes in adolescents living in urban areas has not been established., Objective: To determine the long-term effects of a peer-led program on asthma control, quality of life, and asthma management among predominantly racial and ethnic minority adolescents living in urban areas., Design, Setting, and Participants: A parallel-group, randomized clinical trial was conducted in 2015 to 2019 in 3 metropolitan cities in the US: Buffalo, New York; Baltimore, Maryland; and Memphis, Tennessee. Adolescents aged 12 to 17 years old with persistent asthma were recruited mainly through clinical practices and schools. Participants were followed-up for 15 months after the intervention. Double-blinding was achieved for baseline. Data analysis was performed from June 2019 to June 2020., Interventions: The intervention group received a peer-led asthma self-management program; the control group received the identical program led by adult health care professionals. Peer leaders made follow-up contacts every other month for 12 months., Main Outcomes and Measures: The primary outcome was quality of life measured by the Pediatric Asthma Quality of Life Questionnaire, which consists of 3 subscales that measure symptoms (10 items), activity limitations (5 items), and emotional functioning (8 items) in the past 2 weeks. Each item was measured on a 7-point scale, with higher mean scores indicating better quality of life. Secondary measures included the Asthma Control Questionnaire and an asthma self-management index capturing steps to prevent and manage symptoms, self-efficacy, and lung function., Results: Of 395 eligible adolescents, 35 refused, 38 did not show or were lost to contact, and 2 withdrew before randomization; 320 adolescents participated (mean [SD] age, 14.3 [1.71] years), including 168 boys (52.5%), 251 Black or African American adolescents (78.4%), and 232 adolescents (72.5%) with public health insurance. Of 320 enrolled, 303 were included in the longitudinal analysis. Response rates were 80% or higher at all time points. The peer-led group had greater improvement in outcomes than the adult-led group, with adjusted mean differences (AMDs) between baseline and 15 months of 0.75 vs 0.37 for quality of life (between-group AMD, 0.38; 95% CI, 0.07 to 0.63) and -0.59 vs -0.31 for asthma control (between-group AMD, -0.28; 95% CI, -0.51 to -0.01). Outcomes were not affected by bimonthly contact doses., Conclusions and Relevance: In this randomized clinical trial, a peer-led asthma self-management education was more effective than an adult-led program in improving asthma outcomes, with the improvements sustained for up to 15 months. These findings suggest that a peer-led asthma self-management program should be considered in addressing the disproportionate asthma burden in racial and ethnic minority adolescents living in urban communities., Trial Registration: ClinicalTrials.gov Identifier: NCT02293499.

Abstract: Advanced practice registered nurse (APRN) programs are challenged to provide clinical learning experiences that prepare graduates with the full continuum of expected competencies. Preparing the APRN in academia, in terms of didactic and clinical application for novice entry, is often a vexing balance between board certification preparedness and the actualities of clinical practice. This article presents an innovative strategy to examine the perplexing reflective question often asked by educators: Does the current approach for simulation development prepare our APRN students sufficiently for entry into practice, and is it current to what is occurring in practice?, Competing Interests: The authors have declared no conflict of interest., (Copyright © 2021 National League for Nursing.)

Collecting accurate healthcare utilization (HCU) data on community-based interventions is essential to establishing their clinical effectiveness and cost-related impact. Strategies used to enhance receiving medical records for HCU data extraction in a multi-site longitudinal randomized control trial with urban adolescents are presented. Successful strategies included timely assessment of procedures and practice preferences for access to electronic health records and hardcopy medical charts. Repeated outreach to clinical practice sites to identify and accommodate their preferred procedure for medical record release and flexibility in obtaining chart information helped achieve a 75% success rate in this study. Maintaining participant contact, updating provider information, and continuously evaluating site-specific personnel needs are recommended., (© 2021 Wiley Periodicals LLC.)

Objective: To examine the long-term effects of a peer-led asthma self-management program on urban adolescent peer leaders with asthma., Methods: This longitudinal study includes 51 adolescents (16-20 years) enrolled in an asthma self-management program implemented at a one-day camp as peer leaders. Study outcomes, including quality of life, asthma control, asthma knowledge, and attitudes toward asthma were collected for 15 months post-intervention. Mixed-effects models were conducted to estimate time effects, and effect sizes were calculated for each model., Results: Of 51 enrolled, 41 completed the training, of which 35 successfully participated in the camp program. A total of 17 peer leaders withdrew between enrollment and 15-months follow-up. Quality of life, asthma control, and knowledge significantly improved after peer leader training and remained elevated for 15 months, while significant improvement in attitudes emerged immediately after camp, in which they served as leaders, and sustained for 15 months., Conclusion: This study demonstrates the long-term positive effects of a peer-led program on a wide range of asthma outcomes in urban adolescent peer leaders., Practice Implications: A peer-led approach to asthma education providing peer leaders with intense training and leadership experience can be effective and sustainable in improving asthma outcomes among urban adolescents., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Adolescents with asthma are influenced by peers and family. The objective was to better understand family social support and test its association with medication adherence, asthma control, and Emergency Department (ED) use., Methods: This study is a cross-sectional secondary data analysis from a randomized controlled trial with urban adolescents from three U.S. cities. Participants (12-20 years old) with asthma completed the Perceived Family Support Scale (PFS) and Horne's Medication Adherence Report Scale (MARS). Data from both tools were classified into 2 categories- high and low (< 25 th percentile) perceived family support and high (total score >10) and low medication adherence, respectively. Chi-square statistic and logistic regression were used for analysis., Results: Of the 371 participants, the majority were young (96% ≤ 17 years), African American or Bi-racial (85%), and Medicaid-insured (72%); over one-third had maternal family history of asthma. Among those on a controller medication ( n  = 270), only 37% reported its use ≥8 days over 2 weeks. Asthma control was poor with 50% categorized "not well controlled," 34% "very poorly controlled." Participants responded positively to most social support items. One item, providing and receiving social support to and from family members, was less often positively reported. Low medication adherence was significantly associated with lower perceived social support ( p  = 0.018)., Conclusion: This study underscores the importance of family social support in understanding the extent of adolescents' self-management, particularly medication adherence.

Harmful use of alcohol has serious effects on public health and is considered a significant risk factor for poor health. mHealth technology promotes health behavior change and enhances health through increased social opportunities for encouragement and support. It remains unknown whether these types of applications directly influence the health status of young people in reducing harmful levels of alcohol consumption. The purpose of this systematic review is to examine current evidence on the effectiveness of mHealth technology use in positively influencing alcohol-related behaviors of young people without known alcohol addiction. Relevant articles published from 2005 to January 2017 were identified through electronic searches of eight databases. Studies with interventions delivered by mHealth (social networking sites, SMS and mobile phone applications) to young people aged 12-26 years were included. Outcome measures were alcohol use, reduction in alcohol consumption or behavior change. Eighteen studies met the inclusion criteria. Interventions varied in design, participant characteristics, settings, length and outcome measures. Ten studies reported some effectiveness related to interventions with nine reporting a reduction in alcohol consumption. Use of mHealth, particularly text messaging (documented as SMS), was found to be an acceptable, affordable and effective way to deliver messages about reducing alcohol consumption to young people. Further research using adequately powered sample sizes in varied settings, with adequate periods of intervention and follow-up, underpinned by theoretical perspectives incorporating behavior change in young people's use of alcohol, is needed.

The risk of alcohol related harm is experienced disproportionality by young people aged 15-24 years. Harmful use of alcohol has serious effects on individual physical and mental wellbeing and is considered by the World Health Organization to be one of the main risk factors for poor health globally. It is crucial to understand the factors that influence drinking behavior in young people in order to inform prevention strategies to prevent problematic drinking. This is particularly paramount during the transition into young adulthood (around 18-25 years), when risky health behaviors are likely to become embedded. This pilot study adopted a qualitative descriptive methodology that facilitates exploration of what young people say about their own experiences and behavior, as it relates to SNS use and alcohol consumption. Semi-structured interviews were conducted in Newcastle, NSW Australia. An inductive, semantic approach to thematic analysis was selected to analyze the data as this method supported the exploratory nature of the pilot study and ensured that the themes identified were strongly linked to the data. Four main organizing themes that arose from the collected data were: organizing friends; safety amongst friends, planning not to plan; and different event - different plans. All of the participants stated they preferred to use Facebook Messenger™ to connect and share in a group conversation with peers. Convenience, cost and accessibility emerged as the main reasons for using SNSs to plan nights out. Planning for a night out using SNSs allows young people to impulsively plan and change plans - making planning fluid and asynchronous. To date, despite the global use of SNSs, the influence of SNSs in young adults' planning for events during which alcohol is served is relatively unknown. This pilot study gives us a some understanding of how young people use SNSs to plan and prepare for a night out where alcohol is served. Further research needs to be conducted to determine whether SNSs can be used effectively to promote health behavior change or be used as forums for advice seeking and support when attending events where alcohol is served, with the ultimate goal of lowering risky behaviors and thereby improving health outcomes for young people.

In this paper we compare the fidelity of a Peer-Led Asthma Self-Management Program for Adolescents (PLASMA) and its attention control. A randomized controlled trial involving two groups-the PLASMA group and the attention control group-was conducted between 2015 and 2018. Adolescents 12-17 years old (N = 259) in three cities in the United States received asthma self-management education implemented at a day camp, followed by bi-monthly, follow-up contact for 12 months. Thirty-five peer leaders and six adult educators implemented education sessions for the PLASMA and the attention control groups, respectively. The intervention was the peer-led delivery of the content instead of the educational content itself. This study compares the extent to which the education sessions and follow-up contacts were implemented in accordance with the study protocol by the peer and adult educators. Most topics on asthma knowledge and skills (85-95%) were delivered as intended at an adequate pace in both groups. Peer leaders missed more content in the psychosocial domain than adult educators-14% versus 0%, respectively (t = -3.7; p = .010). PLASMA participants reported high content and time fidelity for all education sessions (94% to 97.6%). Greater success in bimonthly follow-up contacts was reported in the attention control groups, with 4.6 ( ± 1.5) contacts on average compared to 2.6 (±2.02) in the PLASMA groups (t = 9.02; p < .001). Most components of the asthma self-management program were implemented with high fidelity in both groups. The relatively low fidelity in delivering psychosocial content and performing follow-up contacts in the PLASMA groups underscores the need for intensive training to enhance peer leaders' competency with managing these aspects of PLASMA to maximize fidelity. Peer leaders can implement asthma self-management educational components of the intervention with high fidelity similar to adult educators., (© 2019 Wiley Periodicals, Inc.)

Introduction: Pediatric patients who develop acute kidney injury (AKI) while hospitalized have longer hospital stays, increased morbidity and mortality, and are at an increased risk for developing chronic kidney disease. Early recognition of AKI is becoming a major clinical focus. There is little research focusing on nursing interventions that may affect a pediatric patient's risk for developing AKI. The purpose of this review is to summarize reported predictors of AKI to improve its early recognition and treatment among hospitalized pediatric patients., Methods: A review of research was conducted to further identify risk factors of AKI among noncritically ill hospitalized pediatric patients., Results: The current literature demonstrated inconsistent findings in early recognition of AKI among hospitalized pediatric patients., Discussion: Interventions for early recognition and treatment of AKI should consider other variables, such as previous history of AKI and fluid status as risk factors, warranting additional research., (Copyright © 2019 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Children with asthma are targeted for influenza vaccine because of their vulnerability to complications, particularly those with low income or family preference for Spanish language. We used text messaging to encourage caregivers to vaccinate. Participants were children (aged >6 months), predominantly low income and Latino, with an asthma diagnosis attending a pediatric clinic. Interactive text messages that described the vaccine and how to make an appointment were sent to parents in English or Spanish, January 2016 to April 2017. Year 1 messages were evaluated by the investigators considering vaccination results and evidence in the literature. Improvements for Year 2 included timing of message, clarity of message, and using the family language of preference. Messages went to 398 (Year 1) and 485 (Year 2) families. Sixty-four percent of families preferred English; 35% preferred Spanish. Children in Spanish-speaking families were significantly more likely than children in English-speaking families to be vaccinated, 66% versus 46%. Text messaging is a straightforward, low-cost health promotion strategy with potential to improve child health. Quality improvement efforts in outpatient settings with low-income and limited English proficiency families are needed. mHealth strategies may help address the needs of vulnerable populations. SQUIRE V.2.0 guidelines were used for manuscript writing and reporting.

Nurse-graduates today must be prepared to practice in a complicated healthcare system with numerous safety challenges. Although patient safety and quality competencies are a priority in nursing education, effective strategies for applying this knowledge into practice are needed. To meet this challenge, the Helene Fuld Leadership Program for the Advancement of Patient Safety and Quality at Johns Hopkins School of Nursing has developed an academic-clinical service partnership. Students are assigned to mentored, quality improvement projects in which they complete 100 hours over 2 semesters. This partnership links the Fuld Fellows with an interprofessional network of Johns Hopkins Medical Entity clinical Quality Improvement leaders. The partnerships have lead to manuscripts, professional job opportunities, and quality networking for both our students and mentors. Our strategic, academic-service partnership has improved student knowledge of patient safety principles and promoted nursing competence in patient safety with the development of future patient safety and QI nurse leaders., (Copyright © 2018. Published by Elsevier Inc.)

Background: Research in genetics and genomics has led to the development of precision medicine, with health care increasingly individually based on one's genetic makeup. Implementation of genetics and genomics in primary care has been challenging given the rapid development of new advances. Clinicians report difficulties incorporating genetics and genomics in practice, citing insufficient knowledge, training, confidence, and resources for genetic diagnoses, testing, and result reporting., Method: Three pediatric nurse practitioner students participated in elective clinical rotations in pediatric genetics, with the goals of approaching all patients with genetic thinking, gaining competence collecting family health histories, and understanding available genetic resources., Results: Postrotation, students gained genetic thinking skills, competence collecting a three-generational family health history to assess genetic risk factors and aid in genetic diagnosis, and the ability to navigate genetic resources., Conclusion: Genetics clinical rotations during primary care nurse practitioner education is an effective strategy to learn genetic and genomic competencies. [J Nurs Educ. 2018;57(11):690-693.]., (Copyright 2018, SLACK Incorporated.)

Aims and Objectives: To determine what is known about hypertension among adults living in Haiti., Background: Hypertension is the leading cause of morbidity, the identified cause of heart failure in 45% of patients and is associated with more than 70% of cardiovascular disease-related hospital admissions in Haiti., Design: An integrative review of the literature., Methods: Searching four databases from 2007 to 2018, Whittemore and Knafl's method was used to review the literature. Three nurse researchers independently reviewed and appraised each publication applying the Johns Hopkins Evidence-based Practice Appraisal tool., Results: Eight publications were identified and appraised for level and quality of evidence. The synthesis of the literature yielded common themes of (i) high prevalence of hypertension among adults living in rural areas, (ii) public health challenges, (iii) lack of knowledge and awareness of hypertension and (iv) barriers to effective treatment., Conclusion: Hypertension is a highly prevalent disease in Haiti that is understudied and warrants attention. To better serve this vulnerable population, culturally tailored prevention strategies and disease management programmes are recommended., Relevance to Clinical Practice: There is a lack of quality evidence to guide nurses in the management of hypertension for this vulnerable population. Identification of barriers to effective treatment among this underserved population will assist nurses and other healthcare professionals in identifying best possible practices for patient care in clinical settings across Haiti., (© 2018 John Wiley & Sons Ltd.)

Intervention studies with urban adolescents and families affected by asthma are critical to improving the disproportionate morbidity in this population. Community-based recruitment and retention strategies in a multi-site longitudinal project evaluating an asthma self-management intervention for adolescents are presented. Successful recruitment strategies depended on the geographic and cultural characteristics of each study site. Partnering with providers and groups known to the target population and in-person contact with target population were found effective. Flexibility accommodating modified and new approaches, securing multiple contacts and repeating mailings as well as capitalizing on the benefits of subject payment was critical to achieving long-term subject engagement of 85% in the study. Ongoing monitoring and adjustment of recruitment and retention strategies is recommended., (Copyright © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.)

Introduction: The purpose of this qualitative study was to explore beliefs about breastfeeding among Latina mothers. The focus groups were part of a sequential mixed methods study., Methods: Two focus groups were conducted. Participants were Spanish-speaking mothers with infants younger than 12 months. Focus groups were conducted in Spanish and audiorecorded. The researchers performed open coding of the data, compared and converged codes, and identified common themes and relationships among the themes., Results: Mothers described concerns about adequacy of breastfeeding for their infants' needs, the continued goodness of breast milk, and weaning. They expressed lack of knowledge about using breast pumps and other assists that could help them breastfeed., Discussion: Culturally tailored breastfeeding education and support have not been adequately implemented in this urban clinic and likely in other similar settings. More targeted attention to this population could improve exclusive breastfeeding of infants and ultimately result in better child health., (Copyright © 2017 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Patient activation (the knowledge, confidence, willingness, and skills to manage one's healthcare) and health literacy have well-established associations with health and healthcare outcomes in adults. However, little is known about parent activation on behalf of children and its relation to health literacy. Our objective was to examine relations between parent activation, health literacy, and parent-provider relationship quality. We surveyed 316 Spanish- or English-speaking parents of publicly-insured patients of a general pediatrics clinic. Surveys included the Parent-Patient Activation Measure (P-PAM), the Newest Vital Sign (NVS), and parent-provider relationship measures. We used chi-square analyses and logistic regression to explore associations stratified by survey language. Spanish-speaking parents had significantly lower levels of both parent activation and health literacy compared with English-speaking parents (p<.001). Parent activation was not associated with health literacy, suggesting that they are distinct concepts. Because parent activation is a more easily modifiable trait than health literacy, it may present an opportunity to improve outcomes in less health literate populations. We did not find expected associations between parent activation, health literacy and parent-provider relationship quality. Further study is needed to understand how parent activation relates to pediatric outcomes, and if it is an appropriate intervention target to address child healthcare disparities in populations with limited health literacy.

Haitians continue to rebuild following the devastating earthquake in 2010, as many also strive to recover and heal from associated horrific events. Immediately following the earthquake, domestic and international agencies reported dramatic increases in violence against women and girls in this small Caribbean nation that shares the island of Hispaniola with the Dominican Republic. In this article we highlight one segment of a situational analysis used as groundwork for developing an intervention to address gender-based violence (GBV). We sought to rapidly identify existing and needed resources and services for internally displaced women and girls in Haiti and to facilitate an immediate and sustainable response. During an eight-day period, we convened focus groups in Port au Prince. Displaced women and older girls, directors of nongovernmental organizations (NGOs), healthcare providers and administrators, and community youth leaders participated in the focus groups. Findings from these focus groups illuminate the multiple influences of GBV on displaced women and girls. Gaps, strengths, and limitations of existing resources, capacities, systems, and services for internally displaced Haitian women and girls were identified. In addition, factors that could potentially support or hinder effective implementation of preventive and response interventions were revealed. Our findings provided a foundation and structure for developing a culturally- specific educational and safety plan which was used in Haiti following the earthquake and continues to have relevance for use, today., Competing Interests: Declaration of Interest Statement: The authors declare no conflicts of interest.

Aim: To describe the physical, psychological and sexual violence among internally displaced adolescent girls following the 2010 Haiti earthquake and related risk factors, health concerns and cultural norms., Background: Thousands of adolescents were displaced following the earthquake, leaving them vulnerable to abuse and violence. Displaced survivors are disproportionately vulnerable to violence after natural and man-made disasters., Design: A descriptive-correlational design was used to: (1) describe the extent of violence, health risks and concerns in the displaced adolescent girls; and (2) identify correlations in the strength and magnitude of relationships between selected variables including demographics, risk factors and cultural tolerance of violence., Methods: Data were collected from participants using computer-assisted self-interviews between 2011-2013 including demographics, pre- and post-earthquake violence, perpetrators, risk factors and health consequences. Analysis included frequency, logistic regression and multiple regression., Results/findings: A majority reported physical, psychological, or sexual abuse both pre- (59%) and post- (64.1%) earthquake. Pre-earthquake, abused adolescents reported the perpetrator as a boyfriend (50%) or family member (30%). Post-earthquake, 20.5% of physical abuse perpetrators were family members. Pre- and post-earthquake physical and sexual abuse did not change. The risk of being sexually abused post-earthquake increased after controlling for age and education., Conclusion: Displaced adolescent girls reported similar rates of physical and sexual abuse pre- and post-earthquake. These findings show the importance of preventive policies for adolescent girls in disaster situations in countries with low resources. Social and cultural change is critically needed since abuse was at an unacceptably high rate prior to the earthquake., (© 2017 John Wiley & Sons Ltd.)

Objective: (1) To measure healthcare activation among low-income parents by language (English/Spanish); and (2) to assess the psychometrics of the Parent-Patient Activation Measure (P-PAM) in the study population., Methods: We surveyed parents/guardians of publicly-insured children who were established patients at a pediatrics clinic for ≥6months. Surveys included the Parent-Patient Activation Measure (P-PAM), a 13-item measure adapted from the well-validated Patient Activation Measure (PAM)., Results: Of 316 surveys, 68% were completed in Spanish. Mean activation score in the English-language survey group was 79.1 (SD 16.2); mean score in the Spanish-language group was 70.7 (SD 17.9) (p<0.001). Scale reliability was high (English α=0.90; Spanish α=0.93). The P-PAM had acceptable test-retest reliability, but no previously reported PAM factor structure fit the study data adequately for either language., Conclusions: Healthcare activation among low-income parents was greater for parents surveyed in English compared with those surveyed in Spanish. The P-PAM has acceptable reliability and validity in English and Spanish, but a different factor structure than the PAM., Practice Implications: Activation as measured by the P-PAM may not have the same associations with or impact on health/healthcare outcomes in pediatrics compared with adults owing to possible measure differences between the P-PAM and PAM., (Published by Elsevier Ireland Ltd.)

Objectives: Limited research following disasters suggests that internally displaced women are disproportionately vulnerable to violence and abuse. An interdisciplinary collaborative of researchers and practitioners in Haiti, the US Virgin Islands, and the US Mainland investigated gender-based violence (GBV) pre- and post-earthquake and health outcomes among Haitian women living in tent cities/camps following the 2010 earthquake., Methods: A comparative descriptive correlational design using culturally sensitive and language appropriate computer-assisted interviews of 208 internally displaced women 2011-2013., Results: Found high rates of violence and abuse both before (71.2 %) and after (75 %) p = 0.266, the earthquake primarily perpetrated by boy friends or husbands. Significantly more mental and physical health problems were reported by abused than non-abused women. The majority (60-78 %) of abused women did not report personal or community tolerance for violence and abuse, but acknowledged a community context of limited involvement., Conclusions: Coordinated planning and implementation of needed interventions are essential to provide a balanced approach to the care of displaced women after natural disasters with sensitivity to the abusive experiences of many women both before and after the disasters.

The purpose of this study was to explore the perceptions of violence against women (VAW) held by Haitian men to gain a better understanding of why VAW occurs. Women in Haiti have experienced significant violence, both before and following the 2010 earthquake. Fifteen men aged 26 to 47 participated in a focus group. The data revealed three themes: men's beliefs about VAW and its context, factors influencing VAW, and recommended interventions. When approaching VAW, men must be part of the collective effort. Their insights are valuable when planning and implementing interventions to decrease VAW in Haiti and worldwide.

Aims and Objectives: To emphasise the impact of antibiotic resistance as a persistent, global health threat and highlight efforts to improve this complex problem., Background: Political agendas, legislation, development of therapies and educational initiatives are essential to mitigate the increasing rate of antibiotic resistance., Design: Original manuscript., Results: Prescribers, policymakers and researchers are charged with the complex task of mitigating antibiotic resistance in an era when new treatments for bacterial infections are limited., Conclusions: Monitoring, surveillance and incentivising of practice, policy and new treatments provide solutions to antibiotic resistance in both the human and agricultural sectors., Relevance to Clinical Practice: This article emphasises the complexity of antibiotic resistance and highlights the need for a multifaceted approach to improve health care outcomes., (© 2016 John Wiley & Sons Ltd.)

Pure red cell aplasia (PRCA) is a rare disorder characterized by inhibition of erythroid precursors in the bone marrow and normochromic, normocytic anaemia with reticulocytopenia. Among 51 PRCA patients, we identified 12 (24%) patients having monoclonal gammopathy, monoclonal gammopathy of undetermined significance or smouldering multiple myeloma, with presence of monoclonal protein or abnormal serum free light chains and atypical bone marrow features of clonal plasmacytosis, hypercellularity and fibrosis. Thus far, three patients treated with anti-myeloma based therapeutics have responded with reticulocyte recovery and clinical transfusion independence, suggesting plasma cells play a key role in the pathogenesis of this specific monoclonal gammopathy-associated PRCA., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Objective . To determine the breastfeeding rate of Latino infants at an urban pediatric clinic in the first six months of life and to identify factors associated with breastfeeding. Methods . Investigators conducted a retrospective chart review of infants seen at the clinic in 2014 as part of a mixed methods study. Topics reviewed included demographics, infant health data, and feeding methods at 5 points in time. Bivariate correlations and cross-tabulations explored associations between variables. Results . Most of the mothers (75%) fed their newborns with both breastfeeding and formula ( las dos ). At 6 months, a majority were formula-fed only (55.9%). Approximately 10% of mothers exclusively breastfed their newborns, and the trend of exclusive breastfeeding remained steady through the 6-month visit. Over time, the number of mothers who exclusively bottle-feed their infants steadily rises. There were no statistical differences among the feeding method groups with regard to birth order of child, number of adults or children in the household, vaccination rate, number of sick visits, or infants' growth. Conclusions . More targeted attention to this population and other immigrant populations with culturally tailored interventions spanning the prenatal to early infancy periods could increase exclusive breastfeeding and ultimately improve child health., Competing Interests: All the authors declare that there is no conflict of interests regarding the publication of this paper.

Humanitarian workers in disaster settings report a dramatic increase in gender-based violence (GBV). This was true after the 2010 Haiti earthquake when women and girls lost the relative security of their homes and families. Researchers from the United States Virgin Islands and the United States mainland responded by collaborating with Haitian colleagues to develop GBV-focused strategies. To start, the research team performed a situational analysis to insure that the project was culturally, ethically, and logistically appropriate. The aim of this paper is to describe how the situational analysis framework helped the researchers effectively approach this community. Using post-earthquake Haiti as an exemplar, we identify key steps, barriers, and facilitators to undertaking a situational analysis. Barriers included logistics, infrastructure, language and community factors. Facilitators included established experts, organizations and agencies. Researchers in such circumstances need to be respectful of community members as experts and patient with local environmental and cultural conditions.

Purpose: Many parents of young, febrile children lack evidence-based tools to manage fever (knowledge, skills, confidence, support), fear negative outcomes, and prioritize the reduction of fever over management of its source. This review examines the literature for evidence of factors that must be considered when designing effective fever management educational interventions for parents, especially those whose health literacy is low., Data Sources: A systematic search identified studies from 1980 to 2011 using the databases PubMed, CINAHL, Embase, Cochrane Review, Web of Science, PsychInfo, Medline Plus, Joanna Briggs Institute, and Google Scholar., Conclusions: The most effective educational interventions are 1:1, multidimensional, structured, relevant, and reinforced over time. Parental culture, health literacy, knowledge deficits, and beliefs must be addressed by nurse practitioners (NPs) to maximize evidence-based behaviors., Implications for Practice: Parents often strive to do what is best for their child but may become overly protective and anxious when managing their child's fever. NPs have a prime opportunity to improve parents' fever management practices. An evidence-based toolkit, created with respect for those who may have low health literacy, will give parents tangible tools to help them provide safer and less costly care for their febrile child., (©2014 American Association of Nurse Practitioners.)

Aims and Objectives: To evaluate the impact of a provider focused quality improvement educational intervention on appropriate prescribing for community associated methicillin-resistant Staphylococcus aureus infection., Background: Patient, provider and health system factors contribute to appropriate antibiotic prescription. Achieving appropriate prescribing is critical in decreasing the burden of antibiotic resistance. Knowledge of appropriate prescribing for community associated methicillin-resistant Staphylococcus aureus infection is the first step in shifting prescriber behaviour to evidence-based recommendations., Design: Quality Improvement Project., Method: Following a review of best practice guidelines and application of the Stetler Research Utilization model, a brief educational intervention was delivered using voice over PowerPoint. Items in the educational intervention included indications for screening, particularly focusing on the role of watch and wait after culturing for simple abscesses. The intervention was delivered in a for-profit, nonacademic, urgent care setting, and assessed prescribing providers' knowledge and practice., Results: Out of 48 medical doctor, physician assistant and nurse practitioner providers, 18 (37·5%) participated; 12 of the 18 (67%) participants showed an increase in knowledge. Forty three per cent of prescribers' charts demonstrated improved practice through use of the guidelines. Out of 18 prescribers, 44% sent a total of 21 cultures for abscesses. There was no difference in practice behaviours between professional groups., Conclusions: In spite of the increase in knowledge scores, this improvement in knowledge did not translate in dramatic change in practice, although trends in a positive direction were noted., Relevance to Clinical Practice: This quality improvement project underscores the complexity of changing prescriber behaviour and the need for ongoing interventions., (© 2014 John Wiley & Sons Ltd.)

Purpose: The purpose of this quality improvement project was to evaluate adherence to Papanicolaou (Pap) test guidelines 6 months prior to and 6 months following a 30-min educational clinical practice meeting in a pediatric primary care office. Guidelines for Pap tests have been revised in recent years by the American Academy of Obstetrics and Gynecology, the American Cancer Society, and the U.S. Preventive Task Force, but providers often do not adhere to the guidelines., Data Sources: A total of 777 charts from a pediatric primary care office were reviewed. Eighty-four percent (652) met criteria for inclusion., Conclusions: Among sexually active adolescents, there was a statistically significant relationship between rates of Pap tests following the clinical practice meeting (χ(2) (1) = 13.5, p = .001). Prior to the meeting there were 29 Pap tests recorded, whereas after there were two Pap tests done. After the focused clinical practice meeting, providers performed far fewer Pap tests, which is in accordance with the guidelines for this population., Implications for Practice: Providers may not always practice in accordance with recommended clinical practice guidelines for various reasons. Focused, in-office educational interventions via clinical practice meetings may be an effective way of discussing recommended guidelines to improve provider adherence., (©2013 The Author(s) ©2013 American Association of Nurse Practitioners.)

This case study provides a discussion of the diagnosis, management and comprehensive plan of care for empyema in children for the advanced practice registered nurse (APRN) working in primary care. The incidence of complicated pneumonias including those progressing to empyema is on the rise among pediatric patients. The ambiguous signs and symptoms of complicated pneumonias create a challenge for the provider when developing an accurate diagnosis and plan of care. Pediatric nurse practitioners must be cognizant of the increased incidence of complicated pneumonias and manage their patients accordingly. If left untreated, empyema may result in severe pulmonary complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to explore the experiences of volunteer nurses after the Haiti earthquake, January 2010., Design: A descriptive qualitative study design using in-depth interviews focuses on experiences of 12 American nurse volunteers who served in Haiti following the 2010 earthquake., Methods: Semistructured interviews were conducted in person or by phone using an interview guide. The interviews were audio-taped, transcribed, and checked for accuracy. Data analysis was assisted using NVivo9., Findings: Six themes emerged: initial shock, relentless work, substituting and making do, questioning, systems building, and transitioning back., Conclusions and Implications: Nurses who are interested in volunteering after a disaster can expect the experience to be overwhelming and will require them to exercise great flexibility, creativity, and strength in their nursing practice. Nurse volunteers can expect a rewarding experience that will likely change their perspective on nursing work and personal life.

Purpose: The purpose of this study was to explore the experiences of nurse volunteers caring for children after the Haiti earthquake in January 2010., Design and Methods: This descriptive qualitative study using in-depth interviews focuses on the experiences of 10 nurse volunteers., Results: Four themes emerged: hope amid devastation, professional compromises, universality of children, and emotional impact on nurses., Practice Implications: Nurses who volunteer after natural disasters have rich personal and professional experiences, including extremes of sadness and joy. Nurse volunteers will likely need to care for children. Nurses and humanitarian agencies should prepare for the unique challenges of pediatric care., (© 2012, Wiley Periodicals, Inc.)

Health care providers are challenged to use culturally appropriate, low-technology approaches to improve child health in resource-poor countries. Village fathers' clubs is one approach used in rural Haiti since 1994. Fathers meet regularly for health education and community-building activities. Our aim was to investigate parenting practices and beliefs among Haitian fathers of young children and to explore their views on fathers' clubs. We conducted semistructured interviews with 18 fathers. Themes identified were fathers' involvement in routine care of their children, the close partnerships of fathers and mothers in child care, fathers' responsibilities to their communities, and fathers' clubs as an important supportive institution for the Haitian fathers and their families. Rural Haitian fathers reported taking a very active role in the lives of their families and children. Increased involvement of fathers should be explored as a strategy to improve child health and survival in other parts of Haiti and throughout the world.

Introduction: In 2005, a team of U.S. physicians, nurse practitioners, nurses, pharmacists, emergency medical technicians and lay support personnel provided health services in an isolated town in rural Haiti., Methods: During one week, the team saw 788 patients. They recorded age, sex, vital signs, diagnoses, and treatments in an electronic database. A descriptive analysis is presented., Results: Intestinal parasitosis was the third most common diagnosis overall, and the most common diagnosis for children. For adults aged 50 years or older, 52% of women and 37% of men had elevated blood pressures, significantly more than adults aged 15-49 years., Discussion: This paper focuses on intestinal parasitosis and hypertension. Periodic anti-helminthic treatment and community sanitation are discussed as ways to reduce the burden of parasites and secondary malnutrition. Challenges to implementing a sustainable antihypertensive program are discussed, including patient education, medication availability and prioritization, and adequate follow-up in a very austere rural setting.

In recognition of the important role that fathers play in the lives of young children in Haiti, a public health organization instituted fathers' clubs in 1994 as a strategy to improve the health outcomes of children. Fathers' clubs focus on child and family health education. To evaluate the effectiveness of fathers' clubs, we examined the health of children born in Haitian villages with and without active fathers' clubs and compared results for the two groups. The presence of a fathers' club in a child's birth village had a positive effect on vaccination status, growth monitoring, and vitamin A supplementation after we controlled for socioeconomic status, time, and the quality of the village health agent. Child weights and mortality were not affected by the fathers' clubs.

International clinical placements offer interested nursing students unique opportunities for development of nursing expertise and cultural competence skills. The authors review the professional literature regarding nursing student experiences in international sites, describe the development of international clinical sites in a required baccalaureate public health nursing course, and summarize challenges and benefits of the program.

Background: Aplastic anemia (AA) complicated by menorrhagia is treated with transfusion and hormonal therapy. When bleeding is life-threatening, balloon endometrial ablation can safely be used to treat menorrhagia in selected patients., Case: A 56-year-old postmenopausal woman was diagnosed with AA after several weeks of menorrhagia and pancytopenia. She became heavily alloimmunized after extensive platelet transfusion. During treatment with antithymocyte globulin, vaginal bleeding increased and the platelet count fell to 1,000/microl on supportive measures. After bleeding stopped with use of intravenous Premarin, she was examined in the operating room. There, a clot was removed and appeared to be a uterine caste; hemostasis continued. Transvaginal ultrasound revealed a normal endometrial contour and thin endometrium; endometrial histology was benign. After she completed antithymocyte globulin and her platelet count could be maintained over 30,000/microl with matched platelets, endometrial ablation was performed without any complications., Conclusion: Thermal balloon endometrial ablation is an effective alternative to hysterectomy for women with persistent menorrhagia and AA when supportive measures fail. Prior to endometrial ablation, evaluation should ensure normal endometrial contour and histology, and that sufficient blood products are available to maintain platelet counts above 30,000/microl during the healing process., ((c) 2008 S. Karger AG, Basel.)

Objectives: This paper describes an innovative public health nursing strategy, village-based fathers clubs, to improve child and family health in rural Haiti. It discusses related nursing implications in Haiti and other parts of the world., Design: Relevant current literature was reviewed and evaluated with respect to child health in Haiti and the development of the fathers clubs. Program participants and organizers were consulted., Sample: The fathers clubs in remote areas of Jeremie Haiti, participants and program directors, provided input for this description., Results: Public health practitioners continually face grave challenges when addressing the health care needs in less developed countries. One such case is Haiti, where crushing poverty, poor infrastructure, a failing economy, natural disasters, and chaotic sociopolitical conditions compound these challenges. Public health practitioners, including nurses, must seek creative, culturally-appropriate, low technologic approaches to improve the health of the children and families in the remote villages of Haiti. The institution and support of village fathers clubs is one approach that has been ongoing since 1994. Fathers meet together on a regular basis for health education, support, and community building activities. The curriculum is health-based and facilitated by nurses, with participation by young and old men alike., Conclusions: Participants and organizers believe that family and child health is improved as a result of the groups.

Treatment of HIV-infected patients with highly active antiretroviral therapy (HAART) has altered the natural history of human immunodeficiency virus (HIV) infection by decreasing the frequency of opportunistic infections and altering the expected frequency of hematologic complications and AIDS-related malignancies. Thrombotic thrombocytopenic purpura and thrombosis resulting from protein S deficiency are relatively rare complications of HIV in the United States in patients taking HAART, but are frequent in the developing world where these drugs are not available. Cytopenia, particularly anemia, are more common and result both from bone marrow failure and peripheral destruction. Hodgkin's and non-Hodgkin's lymphoma are still problematic in patients with advanced disease with high viral loads. This review will examine and discuss the diagnosis and management of the hematologic complications of HIV.

Purpose: To present an interdisciplinary, community-oriented primary care nursing model that effectively draws upon the strengths of advanced practice nurses (APNs), both nurse practitioners and community health nurses., Data Sources: Articles in professional nursing journals, international data sources, and the clinical experiences of the authors, both domestic and international., Conclusions: The model, developed domestically, was utilized successfully by APNs internationally in a medical mission endeavor in rural Haiti. Many partners, domestic and Haitian, worked as an interdisciplinary team to deliver quality health care to an impoverished population. Graduate nursing students participated in the program, which offered opportunities and challenges for both novice and expert nurses., Implications for Practice: Nurse practitioners, community health nurses, and nursing faculty members can use this model to enhance their professional practice. They can learn that clients can be optimally cared for whether the community served is domestic or international. Nursing faculty can teach graduate nursing students about the value of partnerships and collaboration.

The importance of cultural competency in all areas of American society is well accepted. Indeed, the evolving demographics of the country make it imperative. A wide range of educational and work settings has addressed the concept, from business and government to education and health. Cultural competency is particularly critical in the realm of healthcare, as the potential impact on quality of health and life is at stake. Nursing is a leader in this field, with a long theoretical and practice history of attention to, and respect for, individual differences. This article reviews cultural competency education in nursing and its respective educational settings. Common threads and different models are discussed. The program components of cultural competency education in one School of Nursing are highlighted. Future directions towards refining cultural competency education are presented.