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Traditional postpartum practices are widely followed by northeast (Isan) Thai women. Poverty, low education, physical distance, inconvenient accessibility to biomedical health care, and influence of seniors in the family kept voices of these women unheard. The purposes of this interpretive phenomenological study are to understand the lived experiences of first-time mothers who follow traditional postpartum practices, to explore the setting of practices, and to reveal how family generates and transmits practices to new mothers. Study was conducted in Sirindhorn district, Thailand, from October 2008 to September 2009. Sixteen pregnant women during third trimester with uncomplicated pregnancy were recruited from prenatal clinic. Data was collected using three methods including two in-depth interviews, several participant observations, and a demographic form. Within-case, across-case, and thematic analysis were used to investigate meanings of traditional practices. Based on Traditional Thai Medicine, caregivers used food, fire, water, and herbs to rebalance postpartum women's self, including body, mind-heart, and energy. Supervised by caregivers, the women live in hot environment and consume hot food and drink to benefit both maternal and child health. Meanings of practices were revealed and presented through four broad themes. Food practice after childbirth addresses meanings related to certain foods which were encouraged to promote breast milk or discouraged to prevent sickness, which was called phit kam. Postpartum healing through heat demonstrated why lying by the fire was important to Isan women. The fire not only helped them retrieve physical health, but also improved beauty and ensured long term wellness. Hot herbal bath: rebalancing blood and wind systems reflected how and why the caregivers used hot water to promote the women's humoral systems and to heal perineal wounds. Lastly, hot herbal concoctions: tonic and lactating promoter explored local herbs used to make the teas taken by women to prevent and cure phit kam, regain health, and increase breast milk production. The findings provide basic knowledge for determining best health care and preventive health service practices. The goal for the future application of this research is to guide the implementation of care plans in the biomedical health care system with an awareness of cultural practices.

Significance– Nursing home (NH) residents use the ED at higher rates than community-dwelling older adults and nearly 2/3 of NH residents cared for in the ED have cognitive impairment (CI). Studies indicate hospitalization of nursing home residents is frequent and often preventable, however little is known about ED use by residents with CI.Methods– Utilizing a 5% random sample of Medicare beneficiaries residing in NHs in the U.S. (n=132,753, of whom 76,961 had CI), this secondary analysis of 2006 MDS and Medicare claims data examined the prevalence of and factors associated with ED use with and without hospitalization, and preventable ED use, and how such utilization varied by the presence and severity of CI. Descriptive statistics were used to describe the study sample. Multinomial logistic regression was used to estimate the dichotomous dependent variables; Poisson regression was used to estimate the continuous dependent variables, controlling for sociodemographic/health characteristics.Results– Sixty two percent (n=82,335) of the sample had an ED visit with or without hospital admission. Residents with CI had fewer total number of ED visits/year compared to those without CI. Controlling for acuity and other factors, the odds and rates of ED use with and without hospitalization varied by both presence and severity of CI. Odds of any ED visit were highest for residents with very mild CI and risk declined as CI worsened. There was a similar trend for ED visits resulting in hospitalization, with 13% higher odds for residents with very mild CI compared to residents without CI; risk also declined as CI worsened. Risk of ED use without hospitalization was greatest for those with mild CI and moderate-severe CI, with 7-12% higher odds of an ED visit without hospitalization/year than those without CI. Almost 24% (n=31,566) of the sample had a potentially preventable ED visit. Residents with very mild-mild CI were at highest risk, with 10-15% higher odds of a preventable ED visit compared to those without CI.Implications– Identifying and modifying factors responsible for ED use during an illness episode may result in more appropriate use of the ED, reduced costs and better health outcomes. Using preventable ED use as a NH quality indicator may be warranted.

Female-to-Male transgenders (FTM), or transmen, have become an increasing presence in the gay community, especially in San Francisco. However, there is little data regarding how they transitioned into the gay community and the risks for HIV and STDs that they faced when they completed transition. This dissertation is comprised of four papers that examine that situation. The first paper describes the ways in which three decades of the HIV epidemic have impacted sexual behavior and attitudes within the gay community. That is followed by a review of what is known and unknown about the development of sexual differentiation and gender identity, with a specific focus on a variety of intersex conditions. The final two papers present the results of the study "Sexual Identity, Behavior, and Risk Among Female-to-Male Transgender Persons". This study used Interpretive Phenomenology to describe and understand the experience of 17 transmen who were recruited in the San Francisco area. Two lines of inquiry were identified for the study. The first was to describe and understand the variability in sexual orientation and behavior among transmen before and after transition and the use of testosterone. The four distinct groups of steadfast, shifted, aligned, and fluid are identified and described in the third paper. The final paper examines the second line of inquiry. This was to identify the risk present for transmen who transitioned into the gay community. Risks inherent in being part of the gay community as well as aspects of risk that are specific to transmen are discussed.

QT interval prolongation on the electrocardiogram is a marker of abnormal ventricular repolarization and is associated with Torsades de Pointes, sudden death, and all-cause mortality in outpatient samples. This is the first inpatient study of acutely ill adults performed to determine the: 1) need for QT monitoring as outlined in American Heart Association (AHA) guidelines, 2) prevalence and predictors of QT prolongation, 3) association of QT prolongation with hospital length of stay and all-cause mortality and 4) ability of acute care nurses to perform accurate QT measurement by routine manual methods. Methods: Special study software (Philips Healthcare, Andover, MA) was installed to measure the QT and heart-rate-corrected QT (QTc) interval every minute in all patients admitted to 5 hospital units over a 2-month period. Patient data were abstracted directly from the medical record. Nurses' knowledge and skills were assessed by pre-post tests conducted during QT-related classes repeated 44 times on all nursing shifts. Nurses were taught how to measure the QT interval from a rhythm strip using hand-held calipers and to calculate the QTc using the Bazett formula. Results: Patients. 67,648 hours of QT data were obtained from 1039 patients. 73% of patients had at least 1 AHA indication for QT monitoring. 24% had an episode of dangerous QT interval prolongation > 500 milliseconds lasting 15 minutes or more. In a multivariate logistic regression analysis, predictors of QT prolongation were female sex, number of proarrhythmic drugs, low potassium or calcium, high glucose or creatinine, and history of stroke or hypothyroidism. An episode of QT prolongation was associated with longer length of stay (11.53 v 5.52 days, p

Nursing is among those believed to be oppressed who are at risk for horizontal violence, yet no known evidence of a relationship between these concepts exists. Studies of horizontal violence suggest that some nurses suffer personal consequences, yet almost nothing is known about the consequences for patients. Furthermore, no known framework exists to guide research to explain these potential consequences. The purpose of the study was to describe staff registered nurses' (RNs) work-related views of themselves, nursing as a group, their interactions and relationships with other RNs, and quality of care. Five hypotheses were tested from the horizontal violence and quality and safety of care model.A random sample of 173 hospital staff nurses drawn from the California Board of Registered Nursing's mailing list participated online or with a paper survey. The Nurses Workplace Scale measured nurses' work-related beliefs exhibitive of an oppressed self or group. The Negative Acts Questionnaire-Revised measured horizontal violence, also called bullying if it occurs frequently. Peer relations, the quality and safety of patient care and adverse events were also measured. Horizontal violence was reported by 21.4% of participants. Nurses' who exhibited more internalized sexism (oppressed group beliefs) reported more horizontal violence (r=.463, p=.000). Nurses' who minimized themselves more (oppressed self beliefs) reported more horizontal violence (r=.451, p=.000). Nurses' who experienced more horizontal violence reported less supportive relationships with peers (r= -.638, p=.000), lower quality and safety of patient care (r= - .459; p=.000), and a higher frequency of adverse events (r= .408; p= .000). Findings suggested that peer relationships mediated the effect of horizontal violence on the quality and safety of patient care, but not on adverse events. Horizontal violence was reported by one fifth of staff nurses in hospitals. Hypotheses tested were supported. Nurses who perceived more oppression of self and nurses as a group reported more horizontal violence. Nurses perceived that horizontal violence negatively impacted peer relationships and the quality and safety of patient care and increased the frequency of adverse events. Education in practice settings is recommended to improve peer relationships in the presence of horizontal violence. Reducing horizontal violence may rely on changing the social structure in hospitals.

Research has determined that anxiety, depression, and fatigue are common problems in oncology patients, and may have negative effects on patients' quality of life (QOL). However, research on gender differences for these symptoms is limited. The purpose of this study was to evaluate for gender differences in occurrence rates and severity of anxiety, depression, fatigue and energy at the initiation of RT, and also evaluate for gender differences in QOL. Participants (n=183) undergoing primary or adjuvant RT were recruited from two RT departments located in a Comprehensive Cancer Center and a community-based oncology program at the time of the patient's simulation visit. Symptoms and QOL were evaluated using the Spielberger State-Trait Anxiety Inventories (STAI-T and STAI-S), the Center for Epidemiologic Studies-Depression (CES-D) Scale, the Lee Fatigue Scale (LFS), and the Quality of Life-Scale-Patient Version (QOL-PV). Statistical analysis was performed by SPSS 15. Independent sample t-tests and Chi Square analyses were used to evaluate for gender differences in demographic and clinical characteristics. In addition, age was entered as a covariate in the univariate analyses of variance that evaluated for gender differences in symptom and QOL scores. The results showed that women reported higher occurrence rates for state anxiety, depression, and lower levels of morning energy compared to men. Women also reported greater severity of depression, evening fatigue, and poorer psychological and physical QOL. Findings from this study suggest that gender may influence patients' symptom experience and QOL. Further investigation is warranted to confirm the findings from this study and to understand the biological, psychological, and social factors that contribute to these differences.

This study of prostate cancer patients who underwent radiation therapy (RT) examined how total sleep time changed from the time of simulation to four months after the completion of RT and investigated whether specific variables predicted initial levels of sleep disturbance and characteristics of the trajectories of sleep disturbance. Eighty-two men completed a number of measures (i.e., wrist actigraphy, General Sleep Disturbance Scale, Center for Epidemiologic Studies-Depression scale, Spielberger State-Trait Anxiety Inventories, Brief Pain Inventory) over six months. Descriptive statistics and hierarchical linear modeling were used for data analysis. Large amounts of inter-individual variability were found in the trajectories of sleep disturbance. At baseline, sleep disturbance were associated with ethnicity, KPS score, total dose of RT, pain at baseline. The trajectories of sleep disturbance in this group of men with prostate cancer were associated with total dose of RT, pain at baseline, total sleep time at baseline, state anxiety at baseline. This study is the first using actigraphy to identify predictors of inter-individual variability in sleep disturbance in men with prostate cancer undergoing RT. Additional research is warranted to confirm this study's findings and to develops and test interventions in this vulnerable group of oncology patients.

Heart failure (HF) is a chronic progressive condition, with debilitating symptoms. Despite the pivotal role family caregivers play in the care of HF patients, family caregiving has received little attention in HF research. The primary aims of this dissertation were to describe the nature of family caregiving in the context of heart failure (HF) and to identify factors associated with the impact of caregiving. A particular focus was on the positive aspect of caregiving and the role of social support on the impact of caregiving. This dissertation includes a review of the literature and findings from three research studies. The first study is a secondary analysis of data from 338 partners of HF patients and 1202 partners of healthy individuals. Care tasks performed by partners were compared between the two groups. Partners of HF patients were more likely to provide personal care and emotional care than partners of healthy individuals, even when only non-HF-specific care tasks were investigated.In the second study, data were obtained from 76 HF patient-family caregiver dyads. Caregiving had both positive and negative impact on family caregivers. The level of caregiver perceived control and social support were important factors in the impact of caregiving measured with the Caregiver Reaction Assessment. The severity of HF and patients' clinical events were also associated with the impact of caregiving. In the third study, family caregiving was examined in the context of a specific etiology of HF, pulmonary arterial hypertension (PAH). Among the 35 family caregivers of PAH patients in the study, 14% were identified as having moderate to severe depressive symptoms. Most caregivers were involved in managing care for the patient and helped the patient with self-management activities. Lower level of social support was significantly associated with more severe depressive symptoms in caregivers. The role of family caregivers becomes increasingly important with the rising prevalence of HF and increased emphasis on self-management. The needs of family caregivers should not be overlooked in clinical practice. Social support and information to meet the demands of caregiving need to be provided to family caregivers in order to optimize the caregiving experience.

abstract

This study uses organizational change, diffusion of innovation, and strategic management theories to explore the adoption and implementation of an innovative process for purchasing chemicals and chemical-containing products at Kaiser Permanente (KP), the largest not-for-profit health system in the United States. Case study methodology and content analysis were used to design and analyze this study. Interviews were conducted with key decision makers at KP headquarters in Oakland, California and with informants from nongovernmental organizations that partnered with KP in purchasing chemicals purchasing efforts. In addition to interviews (n = 19), private and public documents (n = 22) were examined and analyzed to triangulate the data. This exploratory study carefully documents the complex factors that influenced an innovation in the purchase of chemicals and chemical-containing products by an industry leader widely recognized for its environmental stewardship initiatives. This study highlights specific organizational successes at KP in driving the design and manufacture of environmentally preferable product alternatives. However, it also characterizes the substantial contextual and regulatory barriers that KP confronted as it tried to establish a more sustainable base of operations. These barriers included: (a) difficulty acquiring product information; (b) difficulty reducing chemicals and chemicals of concern in the supply chain due to various factors, such as lack of available alternatives; (c) limited organizational resources to pursue or verify product information or create new products; (d) difficulty addressing the large and complex range of products that enter KP's supply chain; and (e) difficulty surmounting barriers posed by existing regulations governing chemicals.

Delirium and sleep deprivation are experienced by patients in intensive care units (ICUs) and have been associated with negative patient outcomes. Benzodiazepine, often used for sedation in critically ill patients, contributes to an imbalance of neurotransmitters that can influence the wake-sleep-regulatory system and the occurrence of delirium. This dissertation evaluated the effect of a sedation wake-up trial (SWT) and spontaneous breathing trial (SBT) on the occurrence of delirium, perception of sleep and other outcomes in trauma ICU (TICU) patients. The first study was a prospective interventional trial that implemented the SWT plus SBT in TICU patients. The intervention group (IG, n = 20) experienced less delirium (OR 0.107; 95% CI: 0.025-0.459), recovered from drug-induced coma faster (RH 2.25; 95% CI: 1.08-4.65), and was liberated from the mechanical ventilator (RH 3.09; 95% CI: 1.45-6.60) and discharged from the TICU sooner (RH 4.20; 95% CI: 1.82-9.69) than the control group (CG, n = 20). Sleep perception was rated as bad and did not differ between groups. A second report addressed the feasibility of conducting the SWT plus SBT based on the ability to implement the combined intervention, measure patients' physiological responses, and maintain patient safety. IG patients passed 67% of the 39 SWTs performed. Those who did not pass presented RASS scores of +1 and +2, tachycardia, or showed ventilator asynchrony. Eighteen patients tolerated their first SBT and after the second SBT more than half of patients were discontinued from the mechanical ventilator. Physiological responses (i.e., heart rate, respiratory rate, and systolic blood pressure) increased significantly from the beginning to the end of the SWT. However, their overall means did not increase by 20%. Opioids were not interrupted during the SWT; however, at the end of six SWTs patients reported having pain. The findings demonstrated that those TICU patients who received the combined intervention decreased in the occurrence of delirium and improved in several outcomes. However, this conclusion is limited by the non randomized design, the small sample, and the lack of control in the type of sedative given to both groups. The combined intervention was well tolerated, safe, and clinically feasible.

AbstractPurpose of the research: The purposes of this study were to evaluate for differences in the occurrence rates of sleep disturbances and fatigue; to evaluate for differences in the severity of sleep disturbance using both subjective and objective measures; and to evaluate for differences in the severity of self-reported fatigue in patients with breast and prostate cancer at the initiation of RT. Methods and Sample: Patients with breast (n=78) and prostate (n=82) were evaluated prior to the initiation of RT using the Pittsburgh Sleep Quality Index (PSQI), the General Sleep Disturbance Scale (GSDS), the Lee Fatigue Scale (LFS), the Karnofsky Performance Scale (KPS) and wrist actigraph. Differences in sleep disturbance and fatigue between groups were evaluated using independent sample t-tests and Chi-square analysis. Key Results: Patients with breast cancer reported significantly higher levels of sleep disturbance (p=0.008) and fatigue (p=0.005) than patients with prostate cancer using subjective measurements. However, according to objective sleep measurements, men with prostate cancer had poorer sleep efficiency (p=0.024) than women with breast cancer. The occurrence rates for sleep disturbance (p

ABSTRACTPURPOSE: This study compared the occurrence rates for and severity of sleep disturbance in cancer patient-family caregiver (FC) dyads.PATIENTS AND METHODS: One hundred and two dyads were recruited from two radiation therapy (RT) departments. Patients and their FCs completed the Pittsburgh Sleep Quality Index (PSQI) and the General Sleep Disturbance Scale (GSDS) and wore wrist actigraphs to obtain subjective and objective measures of the occurrence and severity of sleep disturbance at the initiation of RT.RESULTS: While the occurrence rates of clinically significant levels of sleep disturbance were high for both patients and their FCs, no differences were found between the dyads in these occurrence rates. Very few between group differences were found in the severity of any of the sleep-wake parameters using both the subjective and objective measures of sleep disturbance.CONCLUSIONS: The findings from this study suggest that cancer patients and their FCs experience similar levels of sleep disturbance and that both groups could benefit from interventions that aim to promote restful sleep. In addition to routine and systematic assessment of sleep disturbance by oncology clinicians, interventions are needed that take into account the specific needs of the patient and the FC as well as the potential for partners' sleep patterns to influence one another.

To date, no studies have evaluated for differences in subjective and objective measures of sleep disturbance in oncology outpatients with and without pain. This descriptive cross-sectional study, recruited 182 patients with mixed types of cancer from two radiation therapy (RT) departments at the time of the patient's simulation visit. Approximately 38% of the sample reported moderate to severe pain, with a mean worst pain intensity of 6.2 (SD = 2.4) on an 11-point scale. Significant main effects of pain group were found for the PSQI subscales of quality and disturbance, as well as the global PSQI score with patients in pain reporting higher scores than patients without pain. Significant main effects of pain group were found for the GSDS subscales of quality, medications, and daytime sleepiness, as well as the total GSDS score with patients in pain reporting higher scores than patients without pain. In addition, significant differences in objective reports of nocturnal sleep/rest, daytime wake/activity, and circadian activity rhythm parameters between pain groups were found. These data indicate that pain is prevalent among oncology outpatients and substantially impairs sleep. Further research is warranted to describe more completely the effects of age and gender in the context of pain and sleep disturbances in oncology outpatients prior to radiation therapy.

Acutely and critically ill patients are exposed to many therapeutic procedures that can produce painful experiences. Tracheal suctioning (TS) and wound care procedure (WCP) are frequently performed in these patients. The purpose of this dissertation was to evaluate pain responses during both TS and WCP and to determine the efficacy of a pharmacologic treatment to prevent pain during an open WCP.The first report was a secondary data analysis of findings from a larger procedural pain study. A total of 755 patients underwent the TS procedure that was performed primarily in intensive care units (93%). Pain intensity mean (SD) scores were significantly greater during the TS procedure 3.96 (3.3) than prior to 2.14 (2.8) or after 1.98 (2.7). Few patients received analgesics prior to or during the procedure. Although mean pain intensity during TS was mild, almost the half of the patients who presented pain reported it as moderate to severe. The second study was a randomized, cross-over design with the purpose to determine whether the addition of small doses of ketamine would potentiate morphine's analgesic effects and decrease WCP pain intensity. Patients were randomized to receive morphine plus saline (MS) IV or morphine plus ketamine (MK) IV before the WCP. When the WCP was repeated, patients were crossed-over to receive the alternate treatment. Eleven patients from the Trauma Hospital of Puerto Rico participated in the study. Procedural pain intensity mean ranks during the WCP-MK was significantly less than during the WCP-MS (p = .005). Mean (SD) procedural pain intensity during the WCP-MK was 3.09 (3.27), while it was 6.82 (3.06) during the WCP-MS. However, 91% of patients had adverse effects during MK versus none during MS. In addition, mean (SD) diastolic BP was significantly higher during the WCP-MK than during WCP-MS and prior to WCP-MK, 84 (11.8), 73 (7.4), 72 (12.6), respectively. Individualized pain management must be performed by healthcare providers in order to respond to patients' needs as they undergo painful procedures such as TS and WC. Further research is warranted to determine the dose of ketamine that is analgesic but causes minimal adverse effects during a WCP.

ABSTRACTThe purpose of this descriptive cross-sectional study is to examine the factors that contribute to overweight, decreased physical activity and body dissatisfaction in the 12 to 17 year old, ethnically diverse California adolescent and to determine if there are differences among gender and race. Data from the 2005 California Health Interview Survey (CHIS) for adolescents self-identified as Latino, Asian, or White were reviewed. Adolescents reported weight, height, gender, ethnicity, parent education attainment, household income, physical activity, sedentary activity, breakfast consumption, family meals and body satisfaction. Parent information was also used in exploring factors contributing to decreased physical activity and these variables included parent physical activity, acculturation level and BMI. The main findings in this study were that gender and ethnic variations exist in factors contributing to overweight, decreased physical activity and body dissatisfaction in California adolescents. The key factors associated with both overweight and PA included age, gender, ethnicity, SES, screen time, and parent education attainment. The key risk factors that overlapped for body dissatisfaction and PA included general health status and BMI. A higher percentage of Latino adolescents (38%) compared to 25% of whites and 16% of Asians were overweight. Females are 1.5 times as likely to report decreased levels of physical activity compared with males. Asians were the least active and also reported the highest levels of sedentary activity. Across gender and ethnicity reports of poor/fair general health status and overweight were associated with body dissatisfaction. Latina females and Asian males were the least satisfied with their bodies. Overall, there seems to be a relationship between overweight, decreased physical activity and body dissatisfaction in California adolescents. The findings in this study support the need for development of culturally sensitive and gender specific interventions to improve the health behaviors in the adolescent population.

Women living with HIV/AIDS are challenged to manage the symptoms of HIV/AIDS and its treatment. Peer-based interventions are one strategy that may help women living with HIV/AIDS better manage their symptoms. Peer-based interventions have the potential to enhance health equity in women with HIV/AIDS. It can improve access to health care services, provide support, improve self-efficacy and self-confidence and facilitate involvement in self-care activities. While it has not yet been used with a symptom management intervention in women, recent evidence suggests a peer intervention model may be appropriate to employ in order to change the symptom management behavior in women infected with HIV; but that evidence is needed before wide implementation of it. No studies have been located that have explored the benefits of utilizing a peer-led intervention program to help facilitate symptom self-management for HIV/AIDS in an all-female sample. Therefore, this dissertation presents three papers that address different aspects of the focus of this dissertation, Peer-Based Interventions to Increase Symptom Management in Women Living with HIV/AIDS.

THE EXPERIENCE OF OBESITY AMONG ADOLESCENT GIRLS:A PHENOMENOLOGICAL STUDYMarcia S. WertzABSTRACTThe increased prevalence of childhood obesity in the U.S. has been recognized as a complex and multi-factorial issue that requires a comprehensive and multi-pronged approach to deal with it. Obesity is generally considered a problem of errant lifestyle behaviors around eating and exercise. Current approaches address adolescent obesity by aiming to change lifestyle behaviors at the individual level, in the school, and in the larger community. The objective of this study was to understand the experience of overweight adolescent girls who are at the center of these changes.This interpretive phenomenological study was conducted over a 2-year period. It included participant observation in a San Francisco pediatric obesity clinic, in-depth interviews with 15 obese adolescent girls, home visits and in-depth interviews with 3 mothers of girls in the study, a review of adolescent participants' medical records, a review of San Francisco Unified School District's (SFUSD) board meeting and committee meeting minutes since 2001, and participant observation in the SFUSD student nutrition and physical activity committee.The findings have been grouped under three main themes that were present in the data: the adolescent world, how food is understood, and uncovering "the Look." Within each theme the girl's own closest domestic environment and the public we-world intersect in the experience of the adolescent who is faced with changing her eating behaviors.In being identified as the nexus of the problem of obesity, teenage girls adopt different stances, appropriate to their way of being, to respond to those who want to help them control their weight. "Stance" is the stand a person takes on herself. It is not a conscious, mental or emotional stance, rather it is a non-deliberate, non-contemplated effortless way of being. Stance influences every interaction a person has, including those with the clinic, with school, with peers, and with family. Four prominent stances emerged from the data, and are highlighted for comparison and contrast: oppositional, resistant/bargaining, resigned or accepting, and engaged.Understanding the stance a girl takes may play an important role in the ability to modify her lifestyle behaviors. This is significant for clinicians, who may need to tailor their practice to the stance of their obese patient in order to be effective. This is relevant for policy-makers, as the implication is that social messages, and legislating toward change, must appeal to every stance if they are to be successful in stemming the epidemic of childhood obesity.

Mexican Americans have a high prevalence of type 2 diabetes. Among theelderly, hearing loss is also a significant chronic condition. Understanding of theco-occurrence of these conditions is important for planning screening,intervention and support for a vulnerable population. Aims: The objective of thisstudy was to test a model of predictors of hearing loss in type 2 diabetes. Themodel tested was developed through a process of answering several researchquestions in a two part analysis. Part 1 of the analysis explored the relationshipbetween hearing loss and type 2 diabetes in an existing sample of MexicanAmericans (N=990) from the greater Sacramento area of California. Additionalanalysis in Part 2 was focused on predictors of high frequency hearing loss indiabetes in the sub-cohort of participants with type 2 diabetes (n=405). Methods:A cross-sectional subset of data from the Sacramento Area Latino Study onAging (SALSA) was analyzed to meet the study aims. Analysis includedcorrelations, non-parametric testing, and logistic regression models. Results:High frequency hearing loss in the worse ear was significantly more prevalent inthose with diabetes. In logistic regression modeling, age and gender weresignificant predictors of hearing loss but diabetes was only significantly related tohearing loss in the worse ear. This effect was found to be explained by femalesin the sample as it was not significant for males on gender-specific analysis.Analysis of participants with diabetes revealed that age, gender, and pesticidesuse predicted high frequency hearing loss in the worse ear while age, genderand two diabetes symptom factors relating to energy/fatigue andcardiac/pulmonary symptoms were predictors in the better ear. There was aninteraction effect between diabetes and pesticides use that suggests a need forfurther study to determine if diabetes makes an individual more vulnerable to thenegative effects of pesticides. The results provided partial support for theconceptual model developed for the study and suggested directions for futureresearch on hearing loss in individuals with diabetes.

Most of the knowledge on sleep in older adults with dementia is based on studies conducted in the United States and other Western countries. Sleep research worldwide of other populations with dementia is meager by comparison. The aim of this dissertation is to increase knowledge on sleep in older persons with dementia by studying a Korean population and to suggest effective interventions. Literature on sleep in older adults with dementia was reviewed to identify their sleep characteristics and sleep-related factors and to discuss nursing interventions. Two data-based studies were conducted on a pilot study. A prospective observational study was performed with a convenience sample of 12 older Korean adults with dementia who reside in institutions. The first study examined environmental factors for the effective management of sleep problems in four cases. The second study investigated sleep characteristics, including rest-activity rhythms in institutionalized older Korean adults with dementia, and explored associated factors. Older Korean adults with dementia who reside in institutions experienced fragmented sleep due to frequent nocturnal awakenings and spent extended time napping. The type of institution was a significant factor in rest-activity patterns. Further study with large sample sizes is clearly needed to determine which institutional factors affect sleep and rest-activity patterns in various settings.

The purpose of the descriptive cross-sectional study is to examine the factors that enable or impede cervical cancer screening among Latinas in California. This study applied a well-known theoretical framework for health service usage, the Behavioral Model for Vulnerable Populations, to examine correlates of Pap testing practices among Latinas who were native-born, recently immigrated or established immigrants. Data from the combined 2001, 2003, and 2005 California Health Interview Survey (CHIS) for self-identified Latinas was explored to determine Pap testing practices and rates. Weighted data for 13,889 Latinas were analyzed using multivariate logistic regression models to assess factors that facilitated or presented barriers to Pap testing. This study determined there was an overall decline of 3% by Latinas reporting a Pap test in their lifetime. Latinas who had health insurance, food insecurity, and/or quit smoking were more likely to have received a Pap test in their lifetime. Time since immigration, age, education, marital status, family type, and time since the last physician visit were variables that contributed the least to ever having a Pap test for Latinas in California.The theoretical model used for this study, with its emphasis on economic as well as social and psychological factors, appears to fit the data well and addresses the relevant explanatory factors. This study found that among the three groups: U.S.-born, recent immigrants, and established immigrants, lifetime use of Pap testing was lowest among the recently immigrated Latinas, controlling for other known factors associated with screening. This finding demonstrates the importance of targeting recent Latina immigrants to increase the use of cervical cancer screening. However, the declining trend for both native Latinas and established immigrants in Pap testing rates suggests a need for health professionals to target all Latinas, regardless of immigration status, to increase the rate of Pap testing among this vulnerable group.

ABSTRACTSTAFFING PATTERNS BEFORE AND AFTER MANDATED NURSE-TO-PATIENT RATIOS IN CALIFORNIA'S HOSPITALSTeresa Serratt, R.N., MSN, PhD(c)University of California, San Francisco, 2009Purpose: This study identifies and describes changes in nurse staffing that may have occurred as a result of the enactment of nurse-to-patient ratios and whether these changes were associated with particular hospital characteristics, controlling for market factors and population factors.Background and Significance: Acute care hospitals have faced increased financial pressures from diminishing reimbursement, the proliferation of new medical technology and increased patient severity of illness that required a more skilled workforce. In response to these pressures, hospitals reduced nursing staff with expectations that labor costs would decrease and hospital financial performance would improve. However, reports of medical errors and poor patient outcomes brought this strategy under scrutiny and led to the establishment of mandated minimum nurse-to-patient ratios in California. This study is timely as few studies have been conducted after the implementation of the nurse-to-patient ratios in the state of California to examine the statewide changes in nurse staffing as a result of this legislation. Design and Method: This study utilized a secondary analysis of OSHPD Annual Financial Report data with a pre-post design in which individual hospitals were observed at two time points (1999/2000 and 2005/2006) using ordinary least squares regressions. Key Findings: The descriptive analysis of mean productive hours (MPHs) for nurse staffing indicated nearly an additional hour of medical/surgical registered nurse time per patient day from 1999/2000 (4.36) to 2005/2006 (5.16). Also, medical/surgical registry nurse time per patient day increased from 1999/2000 (0.30) to 2005/2006 (0.88) by more than one half hour. Little changed in the other medical/surgical nurse categories of LVN, nurse aid, and clerical/administrative staff. MPH for `non-nurse' staffing indicated an increase in two staffing categories: diagnostic radiology (0.53 to 1.27) and respiratory therapy (0.35 to 0.83). The other categories (clinical laboratory, physical therapy, pharmacy, and total general services) showed little change in mean productive staffing hours (adjusted by patient days or service volume) from 1999/2000 to 2005/2006. Next, a regression model was calculated to predict changes in MPHs for medical/surgical total registered nurse staff (registered nurses and registry nurses) and found that the `above' category of MPHs in 1999/2000 had a moderate, significant negative association (-1.2497, p=0.013) with changes in MPHs while the below category had a large, positive significant association (0.8761, p

The purpose of this study was to examine the relationship between interpersonal violence and background traumas and symptom distress in a community sample of Colombian women (N = 217). The Life Stressor Checklist-Revised was used to measure lifetime interpersonal violence and background trauma exposure. The Brief Symptom Inventory was used to measure current symptom distress. Although both exposures were common in this sample, interpersonal violence was strongly correlated with current symptom distress; background traumas made no unique contribution to the variance in current symptom distress. The findings suggest that interpersonal events may be particularly distressing.

Optimal Outcomes of Labor and Birth in Water Compared to Standard Maternity CareBACKGROUND: Eleven randomized controlled trials have demonstrated that warm water immersion during labor (WL) safely and effectively reduces obstetric pain. Data are less conclusive regarding underwater birth (WB), although excellent outcomes have been reported for 25,000 cases. This study was designed to address the lack of literature about inpatient WB in the United States, despite availability in 300 hospitals. METHODS: A retrospective cohort study of 13,394 births was conducted at a California community hospital during the first ten years intrapartum immersion was available; 624 WL (4.7%) and 675 WB (5.0%) were identified. Logistic regression and analyses of variance were used to compare perinatal optimality (Optimality Index-United States ratings), care processes and outcomes among three study groups (WL, WB, and standard care), after controlling for medical and obstetric risk factors. RESULTS: Nurse-midwives were the provider type most likely to furnish hydrotherapy (93.6%). WL and WB were most common among English-speaking, nulliparous women with a college or graduate education. Hydrotherapy was associated with specific midwives and labor nurses. Use of pharmacological pain relief methods was five times greater in the non-immersion group than the WB group (OR=5.7, 99% CI= 4.0-6.2, p

Title. Older African Americans and Illicit Drug Use: A Qualitative StudyAim. To explore the underlying social factors associated with illicit drug use in older African Americans as an underpinning to the development of approaches to nursing care and treatment.Background. By 2020 there will be approximately five million older Americans with substance use disorders. A disproportionate number, almost half a million, will be of African descent. Drug use along with age related changes predisposes these older adults to a myriad of undesirable social, psychological, and health outcomes such as homelessness, mental illness, HIV, and hepatitis C.Method. Grounded Theory methodology was used to explore the social processes involved in the use of illicit drugs by older African-Americans. Interviews were conducted with 20 older African American substance users who were currently in drug treatment programs. Responses to the questions were recorded, transcribed, and analyzed using constant comparative methods. The data were collected in 2008.Findings. Three core themes emerged: (1) Family, (2) Media Images, and (3) Environment. Further analysis established that the family and media images themes were components of a larger core category entitled "emulation." Emulation of an admired person or lifestyle was associated with initiation into a drug lifestyle. Environment remained a core category that supported continued and long term substance abuse. Conclusion. Emulation of admired behavior of humans by other humans, unlike the emulation reproduced in the laboratory model by lab rats, occurs in no predictable temporal pattern making the point of intervention for prevention of observed unwanted social behaviors most difficult. However, nurses are in a unique position to assess for and thus intervene against substance abuse initiation and will play a key role in leading the way to healthier communities.

KEEPING PATIENTS SAFE: THE RELATIONSHIP BETWEEN PATIENT SAFETY CLIMATE AND PATIENT OUTCOMESRoxanne Louise O'BrienIncreasing complexity and use of technology in health care has provided life-saving advances in patient care and also increased risks of medical error. Developing a culture of safety and assessing the safety climate or measurable attitudes of staff, in hospitals has been recommended as approaches to enhancing the safety of hospitalized patients. This study used a cross-sectional, descriptive, model testing design to evaluate the relationship between patient safety climate, patient outcomes, staffing, and hospital performance measures. The sample consisted of multiple patient care units and ancillary departments in 10 hospitals. Secondary databases used in this research included responses to a patient safety attitudes survey, unit level patient falls and hospital acquired pressure ulcers, unit staffing data, and hospital level performance measures. Bivariate correlations, descriptive statistics, ANOVA, and hierarchical linear modeling were used to describe unit and hospital level safety attitudes. Patient safety climate was found to vary significantly across units and among hospitals. There were no relationships found between patient safety climate, falls and hospital acquired pressure ulcers. Higher staffing hours in ICU were a confounder in the analysis of a significant relationship between patient safety climate and nurse staffing. A reduction in the failure rate for the community acquired pneumonia hospital performance measure was associated with staff perception of support from unit managers. Understanding how patient safety climate influences the safety of hospitalized patients is currently evolving. Continuing research in this area is warranted to explore this relationship.

Background: While HIV-related stigma has become better understood since the beginning of he HIV/AIDS pandemic, it nevertheless remains a pervasive problem in the prevention and treatment of HIV and AIDS in Africa. Nurses are at the forefront of HIV service delivery, and in many African countries nurses constitute the majority of the health care workers. There is a need to consider the implications of HIV stigma for nurses, but there is a dearth of evidence on nurses' experience with HIV stigma. The objective of this study was to explore the contributions of personal characteristics, job characteristics, and HIV/AIDS stigma on nurses' quality of life. Methods: The study was conducted on site at clinical facilities in five southern African countries (Lesotho, Malawi, South Africa, Swaziland and Tanzania). Using secondary analysis of time 1 data, 1,388 nurses were surveyed using a brief demographic survey, the Quality of Work Life survey, the Medical Outcome Study Short Form 36, and the HIV/AIDS Stigma Instrument (HASI-N). Factor analysis was used in the parent study in the development of the HASI-N to explore concepts, build theory, and/or confirm and test hypotheses about nurses stigmatizing patients and nurses being stigmatized. Multiple regression correlation analysis was used to study the relationship between the predictor variables and criterion variable. ANOVA was used to compare and evaluate the differences amongst the demographic variables.Results: There is a significant negative correlation between stigma and job satisfaction, and there is significant correlation between years of nursing experience and stigma specifically for nurses stigmatizing patients. More stigma is reported if the nurse has a family member or relative who is HIV+. Nurses residing in peri-urban areas reported more stigma than those in urban or rural areas. Overall, the results show that both job satisfaction and nurses being stigmatized affect their physical health and mental health.Conclusions: This study added new information demonstrating that HIV stigma experienced by nurses affects their mental health and slightly their physical health, and this may contribute to the nursing shortage in sub-Saharan Africa.

Factors Associated with Insulin Reluctance in Individuals with Type 2 DiabetesbySoohyun Nam, RN, MSN, ANPABSTRACTBackground: There are many barriers to effective diabetes management for people with type 2 diabetes (T2D) and clinicians. Patients' reluctance to start insulin therapy is one of the barriers to effective management that may be influenced by patients' sociodemographic and psychosocial factors. Significant delay in starting insulin may increase complications and impair patients' quality of life. Little is known about insulin reluctance (IR) and its relationship with associated factors. Purpose: 1) Summarize existing knowledge regarding various barriers to diabetes management from the perspectives of both patients and clinicians; 2) investigate the concept of IR, resistance to using insulin therapy, by describing patients' perceived barriers and their relationships with associated factors; and 3) examine the effectiveness of culturally competent diabetes education (CCDE) among ethnic minorities with T2D.Methods: The first paper was a literature review regarding various barriers to diabetes management. The second study was a cross-sectional descriptive study. Data were collected from 178 people with T2D, who were 18 years or older, being treated with diabetic oral agents and able to speak English. The participants from general medicine practice clinics completed validated measures: Diabetes Attitude Scale, Diabetes Knowledge Test, Diabetes Self-efficacy Scale, Interpersonal processes of Care and Barriers to Insulin Treatment. Biomedical data were obtained from medical record reviews. The third study was a meta-analysis to evaluate the effectiveness of CCDE for ethnic minorities with T2D.Findings: The first paper revealed that patients' adherence, attitude, knowledge about diabetes, culture, language capability, financial resources, comorbidity and social support may affect diabetes management. Clinician barriers to following treatment guidelines include beliefs, attitudes and knowledge, patient-clinician interaction and communication, and the health care system. The second study demonstrated that people with T2D had moderate IR. Fear of hypoglycemia was the strongest barrier to insulin treatment. Women were more reluctant to use insulin than men. Ethnic minorities had more psychological barriers to insulin treatment than whites. Greater diabetes self-efficacy scores predicted significantly less IR and better perceived interaction with the clinician may reduce IR. The third study showed that CCDE appears to be effective in improving glycemic control for ethnic minorities. Word Count: 347

The purpose of this cross-sectional study was to describe attachment behavior in international adoptees at six months postadoption, as well as the child and maternal factors affecting that behavior. Child factors included age at adoption, developmental status, history of care (length of care, number of preadoption placements, and quality of care), and stress level (basal salivary cortisol). The maternal factor assessed was the mother's attachment representations. The convenience sample consisted of 22 adoptive mother-infant dyads from the greater San Francisco Bay Area. Assessment instruments included the Attachment Q-Set, Ages and Stages Questionnaire, History of Care Questionnaire, cortisol analysis, and the Adult Attachment Projective. The major descriptive findings were that 86% of the children were rated secure, with high and low secure groups differing primarily in attachment behavior that involved seeking physical contact with the mother. The factors affecting attachment behavior were analyzed through simultaneous multiple regression. Age at adoption, developmental status, length and quality of preadoption care, and maternal attachment representations were not significant predictors of child attachment status. The number of preadoption placements and the child's stress level did significantly predict attachment status, accounting for approximately 40% of the variance in attachment security. Number of preadoption placements uniquely contributed 14% of that variance (p=.007) while stress level uniquely contributed 12% (p=.01). Children who had fewer preadoption placements had higher attachment security. Similarly, children who had lower stress levels had higher attachment security. Results suggest that consistency of preadoption care was more important than its length or quality. Further, the relationship between stress level and attachment security raises the possibility that a lower stress level functions as a protective factor for the developing attachment with the adoptive mother.

This dissertation reports findings from a descriptive, cross-sectional study on the dyspean experience of Korean immigrants who have asthma and/or COPD; the research is reported in three papers. Little is known about the dyspnea experience and symptom experience in immigrant population in the United States, including Koreans. All data were collected through interviews and structured questionnaires which measure mood, symptoms, dyspnea intensity, dyspnea sensations, dyspnea coping strategies, and functioning. The research reported in the first paper showed that unique descriptors for Korean immigrants with asthma and COPD were blocked chi and they tended to describe dyspnea sensation as rapid. This paper confirmed that dyspnea sensations of Korean immigrants were relatively similar to those of studies of Caucasians. Korean immigrants experience a variety of symptoms other than dyspnea. Multiple symptoms and fatigue were significantly associated with the level of dyspnea, stressing the importance of the assessment of multiple symptoms and continuous effort to manage fatigue in persons with chronic obstructive lung diseases. The research reported in the second paper showed that Korean immigrants used problem-focused strategies (e.g., breathing techniques) more than emotion-focused strategies (e.g., relaxation technique) and reported that emotional strategies were less effective than problem-focused strategies to relieve dyspnea. However, some emotion-focused strategies were more beneficial to Korean immigrants with asthma than with COPD. Korean immigrants have learned coping strategies by trial; little education was provided. They preferred the use of traditional therapies, such as acupuncture or herbs. In addition, their family played an important role caring for them. Therefore, incorporating traditional Korean therapies in pulmonary rehabilitation education as well as enlisting the family participation may improve efficacy in managing dyspnea for this population. Third paper reported that Korean immigrants with asthma and COPD experience a broad range of symptoms that may be the result of multiple coexisting conditions. Age, multiple symptoms, mood, dyspnea, and level of education explained 29.9% of variance in functional performance (F6,78 = 5.534, p = .001). Dyspnea was the most significant predictor of functional performance. This study's findings suggest that continuous emphasis on dyspnea management is warranted to improve functioning in this Korean immigrants.

This study of breast cancer patients who underwent radiation therapy (RT) examined how attentional fatigue changed from the time of simulation to four months after the completion of RT and investigated whether specific variables predicted initial levels of attentional fatigue and characteristics of the trajectories of attentional fatigue. Seventy-three women completed a number of measures (i.e., Attentional Function Index, General Sleep Disturbance Scale, Center for Epidemiologic Studies-Depression scale, Spielberger State-Trait Anxiety Inventories, Brief Pain Inventory) over six months. Descriptive statistics and hierarchical linear modeling were used for data analysis. Large amounts of inter-individual variability were found in the trajectories of attentional fatigue. At baseline, higher levels of attentional fatigue were associated with younger age, not working, a higher number of comorbidities, and higher levels of trait anxiety. The trajectory of attentional fatigue improved over time for women with a higher body mass index at baseline. This study is the first to identify predictors of inter-individual variability in attentional fatigue in women with breast cancer undergoing RT. The various predictors should be considered in the design of future correlational and interventional studies in this population.

Asian Americans constitute one of the fastest growing groups in the United States. This dissertation study explores healthcare disparities in Asian Americans (Asians) through the window of examining those who had coronary artery bypass graft (CABG) surgery in California. The mandatory clinical data registry for CABG surgery, the California CABG Outcomes Reporting Program (CCORP), when linked to California's Patient Discharge Data (PDD), offers a unique opportunity to study Asians. Though the data did not show a significant difference in the overall observed or risk-adjusted operative mortality between Asians and Caucasians, a marginal significant difference was found between Asian females and Asian males (OR, 1.4, p=.057). More significant differences in preoperative clinical characteristics existed between Asians and Caucasians and within genders in Asians. Twice as many Asians had a very low body mass index (BMI)

Background. Community -based participatory research (CBPR) is an egalitarian approach to research that is gaining popularity due to its success in achieving long-term sustainable improvements in community health, yet little CBPR is currently underway in Malawi, Central Africa. Malawians suffer from poverty, food insecurity, HIV and AIDS and have a reported life expectancy of 48 years of age. Although non-governmental organizations (NGOs) have pivotal roles in their work with donors and local communities in addressing these issues, little CBPR literature reflects NGO perspectives.Theoretical framework. Ecosocial theory underpins the study with its dual emphasis on social justice and scientific methods. Health disparities are examined in light of social, environmental and economic constructs as well as from a biological basis.Purpose. The purpose of this research was to explore perspectives of NGO staff in order to understand barriers and facilitators in their work with communities. The study addressed three primary questions: 1) How do NGOs build trust and relationships with community members and agencies?; 2) What are the perspectives of NGO staff regarding their interactions or experiences with donors?; 3) How do Malawi women effect change in their communities? Methods. Using a qualitative, public ethnographic method, 26 semi-structured interviews were conducted in the US and Malawi of staff, volunteers, board members and partners of NGOs and community-based organizations (CBOs). Interviews were audio-taped, transcribed and the data input into Atlas.ti, and analyzed. Findings. Three themes emerged: 1) how NGOs gain community trust; 2) donor power; and 3) how socially disempowered Malawi women effect change in their communities. Study participants consistently advised a bottom-up approach when working with communities and stated that donors and NGOs need to respect cultural norms, listen to community members' priorities, engage communities in activities or research and recognize that communities possess important knowledge. Participants cautioned that while it is easy to slip back into top-down roles, the time and patience required to work from a bottom-up approach does produce long-term sustainable results. Although most participants were unfamiliar with CBPR, their recommendations concur with CBPR principles. Conclusion Community -based participatory research is an appropriate approach to working with Malawian communities.

The portion of older adults with schizophrenia is growing and their physical health status is poor. Many factors contribute to poor physical health including unhealthy lifestyles, poorly managed chronic diseases, and socio-demographic factors. The purpose of this dissertation was to explore how older adults with schizophrenia understand their physical healthA quantitative secondary data analysis was conducted based on a randomized lifestyle intervention program for older persons with schizophrenia or schizoaffective disorder and diabetes mellitus recruited from board-and-care facilities and day treatment programs to explore the relationship between the symptoms of schizophrenia experienced and response to the intervention. The qualitative aspect was conducted using a grounded theory approach to guide interviews with 28 older adults with schizophrenia or schizoaffective disorder recruited from three mental health facilities to explore the individual understanding of physical health. The quantitative study revealed a significant condition by symptom interaction for diabetes knowledge. The difference between change in knowledge for intervention and control groups depends on prevalence and severity of total, negative, and general symptoms. There was not a significant condition by positive symptom interaction for diabetes knowledge. A significant main effect was found between total, negative, positive, and general symptoms in the total sample for diabetes self-efficacy. Higher prevalence and severity of symptoms was negatively associated with improvement in diabetes self-efficacy. The qualitative data revealed that while discussing conceptions of physical health, participants spoke about a sense of belonging as one of the key factors supporting feeling healthy. A sense of belonging could be derived from a sense of connection with others, a physical place, social relationships, and a sense of meaning and purpose. Also, the concept of trust between participants, health care providers, and the health care system emerged as a dynamic process that was built with factors of respect, caring, advocacy, and consistency and eroded through factors of disrespect, not being heard, lack of time, provider inaction, and stigmatization. The symptoms and experience of schizophrenia, the health care system, and health care providers are critical factors to consider in the development of targeted interventions to improve the physical health of this population.

Serious quality of care problems in nursing homes has been a persistent problem in the United States for over 40 years. Staffing shortages and inadequate staff expertise were major contributors to many chronic and recurring quality problems. The purpose of this study was to examine multidimensional associations among organizational characteristics, nurse staffing levels, and comprehensive aspects of quality of care considering resources (payer mix), residents (case mix), and market characteristics. The quality of care was assessed by nurse staffing levels, processes and outcomes of care, and facility deficiencies.From various theories: Donabedian's structure-process-outcome model, organizational theory, and economic theory, a conceptual framework and key factors of nursing home and market characteristics were formulated with the support of previous literature.This study used secondary data from Online Survey Certification and Reporting (OSCAR) data, Minimum Data Set (MDS) 2.0, quarterly staffing data from state inspections, and Area Resource File (ARF). The population of 195 nursing homes out of 199 Colorado freestanding homes in 2000 was used for data analyses. Depending on outcomes, various types of multivariate regression models were used. The major findings of this study were: (1) quality of care in Colorado nursing homes was highly dependent on resources from the external environment, (2) Medicaid reimbursement rates and proportion of Medicare residents were important resources for nurse staffing, and (3) deficiencies in nursing home care were significantly higher in for-profit and chain-affiliated nursing homes. A useful conceptual framework was confirmed with strong support of theoretical background, literature review, and empirical findings. Considering different staffing decisions, regulatory systems need to be designed carefully and systematically to improve quality of care. Given the findings, this study suggests that higher nurse staffing levels can improve quality of care in nursing homes.

Few investigators have focused on grief and bereavement experiences of adolescents themselves, especially from the perspectives of childhood cancer survivors. The purpose of this study using qualitative methods, specifically grounded theory, was to explore grief and bereavement in Korean adolescents who survived cancer following the deaths of friends to the same illness. Specific aims were (a) to explore how the adolescents coped with the death of cancer peers in particular how they interacted with their family and friends, and (b) to identify how culture impacts on their grieving. Data were obtained from Korean adolescents with cancer between the ages of 13 and 23 (N=15) through semi-structured interviews (face-to-face interviews, telephone interviews, and Internet chatting), observations of the social dynamics of participants within self-help groups, and retrieving personal Web journals. Data collection and analysis were conducted simultaneously, and constant comparative methods were used for analysis. Field notes from interviews or observations and memo-writing were integrated into the analytic process. Findings were grouped into three parts. First, participants coped continually with reminders of their grief while interacting with themselves, friends, and their family. To avoid the distress of grieving, participants kept silent, sought solitude, and took care of themselves and others. Second, participants put their grief aside and worked to ease their mother's burden. The conceptual components of filial piety were linked to the ways in which participants made efforts to not show their grief in front of their mothers. They strived to meet parental expectation of carrying on the family lineage, hid their own burden to lessen their mother's worry, reassured their mothers that they will reciprocate the care they received, and attempted to tactfully sense their mothers' feelings and thoughts. Third, cultural considerations such as gate-keeping and multiple strategies to collect data from Korean adolescents were refined based on the understanding of the collectivist culture. The resulting conceptualization of grieving, a theoretical application of filial piety, and methodological reflections will be the basis for future comparative research in grief and bereavement of other cultures, both in Asia and Western countries.

Heart failure with preserved systolic function (HFPSF) accounts for approximately half of all heart failure (HF) patients, a majority of whom are older women. Little is known about this HF subgroup since they have not been included in most HF clinical trials and other research studies. Moreover, the characteristics of those who have advanced disease have not been well described.The primary aims of this dissertation were 1) to use a cross-sectional design to describe the characteristics of older women with advanced HFPSF and 2) to examine potential factors influencing their quality of life (QOL).The variables included were demographic, clinical, symptom, comfort, and functional capacity.Sixty women (76 ± 7.7 years; 86.7% Caucasian) with New York Heart Association Class III HFPSF were recruited from two outpatient HF clinics. The women had high symptom prevalence (13.2 ± 6.4) and burden (2.1 ± 0.43 on a 0-4 scale), impaired functional capacity (mean 6-minute walk distance: 201.4 ± 117.1 meters) and multiple co-morbidities (4.65 ± 1.55). Co-morbid medical conditions associated with increased mortality and morbidity risk in HFPSF included pulmonary hypertension (76%), compromised renal function (73%), atrial fibrillation (66.7%), coronary artery disease (45%), and diabetes (40%). Using a multiple linear regression model to control for disease severity, clinical status, and functional capacity, age (p = .023), comfort (p = .002) and symptom burden (p = .001) were significantly associated with QOL. The final overall model explained 66% of the variance in QOL (p < .001). Age explained 4% of the variance (p = 0.023), total symptom burden explained 14% of the variance (p = < .001), and comfort explained 7% of the variance (p = 0.002) in QOL. Interventions reducing symptom burden and enhancing comfort for older women with advanced HFPSF may result in improved QOL. Addressing factors germane to QOL is congruent with palliative care in advanced chronic illness, since QOL enhancement is a palliative care goal. The unrecognized palliative need of advanced HFPSF patients, a group comprised largely of older women, must be addressed. This segment of our aging society deserves better quality in the last phase of their life journey.

The purpose of this study was to examine the relationship between socio-economic status and established breast cancer risk factors related to endogenous and exogenous hormone exposures. This secondary analysis was based on a subset of data from a large epidemiological study of breast cancer, the Marin Women's Study, in Marin County California. Participants in the Marin Women's Study completed a 20 page self-administered questionnaire. Marin County California is an area with historically higher incidence of breast cancer. Previous efforts to explain the higher rates of breast cancer focused on the region's higher levels of socio-economic status. In a sample of 1,848 respondents, the following variables were examined in relation to education and income levels: age at menarche, age at menopause, total number of years menstruating, age at first pregnancy, number of pregnancies, total cumulative number of months breastfeeding, total number of years of oral contraceptive use, use of fertility medications, and the use of estrogen plus progestin hormone replacement therapy for greater than 5 years. Frequency distributions were calculated for each variable and median values were determined. The median education level obtained by participants was a Bachelor's Degree (34.8%). The median income level range was $150,000 to $299,999 (17.5%). Kendall's Tau-B and Cramer's V calculations showed the degree of correlation between education and income and the hormonal variables. The most significant associations between education, income, and endogenous hormones were not very strong. The greatest correlation was a later age at first birth and increased levels of education (Tau-B = 0.238, p

CARDIOVASCULAR RISK FACTORS IN CAREER FIREFIGHTERSBackground: Sudden cardiac death is the leading cause of on-duty death among career firefighters. Limited literature as to the etiology of on-duty sudden cardiac death in firefighters is available. Cardiovascular risk profiles of firefighters are similar to those of the general population. Firefighters seem not to be protected from the national obesity epidemic; and hypertension and/or hypercholesteremia are often not diagnosed, or are under treated. Methods: Accurately assessing cardiopulmonary capacity in career firefighters is critical to duty assignment and prevention of sudden cardiac death. Eighty-three male career firefighters performed maximal exercise treadmills (per the revised 2008 Wellness-Fitness Initiative (WFI)) and direct VO2max assessments to determine the accuracy of WFI estimates of VO2max and maximal heart rate.VO2 and heart rate at ventilatory threshold and at maximal exercise were measured. They then wore Holter monitors and were asked to record their activities for 24 hours on duty. Subsequently, 63 career firefighters completed a sub-maximal exercise treadmill for comparison to the direct measure VO2max and historical estimates. Results: The WFI maximal exercise treadmill test overestimated ~ 1.16 METs; the initial WFI sub-maximal estimation over-estimated ~ 2.23 METs; and the revised WFI sub-maximal estimation was found to accurately estimate VO2max when compared to directly measured VO2max. Maximum heart rates on duty were analyzed to determine if measured maximal heart rate, or heart rate at ventilatory threshold, were reached. About 18% exceeded their measured maximal heart rate, 51% exceeded their measured heart rate at ventilatory threshold, and 20.5% had an episode of tachycardia while on duty. The most common activity at peak 24-hour heart rate was exercising (32.5%), followed by performance drills (28.9%), pack tests (14.5%), fire suppression and overhaul (10.8%), responding to other calls (9.6%), and other (3.7%). About 90% of the participants experienced elevated heart rates while being monitored. The range of maximum METs demonstrated on duty was 4.8 to 17.0. Implications: Excessive heart rates and work demands may contribute to cardiac compromise if there is underlying cardiovascular disease. Occupational health practitioners should advocate for accurate cardiopulmonary testing and treatment of underlying cardiovascular risk factors in career firefighters.

Breastfeeding (BF) is a health-promoting behavior and exclusive BF has proven economic and ecologic benefits to individuals and societies. Yet Healthy People 2010 BF objectives for exclusive BF remain unmet and prevalence is lowest for low-income populations. The purpose of this descriptive longitudinal study of 126 predominantly low income and ethnically diverse mother-infant dyads was to compare maternal and infant factors associated with nighttime BF behavior between exclusive BF dyads and supplemented dyads. Descriptive statistics, repeated measures ANOVA, independent t-tests, and Chi-square tests were used for analysis.BF behavior was categorized as either 1) exclusive BF, defined as 100% BF or breastmilk feeding on all three nights, or 2) supplementation, defined as any formula during any of the three nights.Compared to women in supplementation (n=59), women in exclusive BF (n=67) were older, more likely Caucasian, working at 36 weeks pregnant but not working at 1 month postpartum, in a relationship, and getting less help with baby at night. There was no group difference in objective sleep at the last month of pregnancy assessment. At one month postpartum, women in the supplementation group averaged 30 minutes less night sleep compared to women in the exclusive BF group.Compared to infants who were supplemented (n=54), infants who were exclusively breastfed (n=66) were significantly more likely to room-in with mothers in hospital and receive a home visit. They were statistically larger at birth, although the difference in size may not be clinically relevant.Assessment of sleep in new mothers is important for BF maintenance and more effort is needed to promote exclusive BF among younger women, African Americans and women of Asian descent. Rooming-in practice in the hospital after birth should be encouraged, as it was significantly associated with exclusive BF behavior at one month postpartum in this diverse sample of new families. Future research using a qualitative approach would be ideal to discover how nighttime feeding for new mothers evolves over time, their motivation for BF, and their network of influence in support of BF behavior. Findings from qualitative research will be useful in developing an effective intervention for BF maintenance.

RISK OF PRETERM DELIVERY AND LOW BIRTH WEIGHTIN SINGLETON PREGNANCIES CONCEIVED BY WOMENWITH AND WITHOUT A HISTORY OF INFERTILITYLoretta B. CamaranoABSTRACTAims: The objective of this study was to determine predictors of low birth weight (LBW) and preterm delivery (PTD) in singleton pregnancies conceived by women with a history of infertility compared to singleton pregnancies conceived spontaneously by fertile woman. Methods: Data were collected at eleven infertility clinics in Northern California. Using a retrospective cohort design, record review was conducted on women who carried singleton pregnancies to greater than or equal to 20 weeks gestation between 1994 and 1998. These women were stratified by method of conception: women who conceived using infertility treatment (n=542), women who conceived naturally following a history of infertility (n=441), and fertile women (n= 1008) identified through California Vital Statistics records. Logistic regression was used to determine whether an association exists between LBW or PTD and infertility or infertility treatment compared to fertile women, controlling for potential confounding variables. Results: There was no significant difference in the frequency of PTD between the three groups of women; however there was a significant difference in the frequency of LBW between the three groups of women (p< .05). 10.8 % of women in the infertile treatment group, 8.6% of women in the infertile without treatment group and 6.4% of women in the fertile group delivered a LBW infant. Women with a history of infertility who had treatment were 1.55 (CI 1.03, 2.34) times more likely to have a LBW infant compared to the fertile group controlling for maternal age, nulliparity, gestational diabetes, and obesity. There was no significant increased odds of delivery of a LBW infant for the infertile without treatment group compared to the fertile group, controlling for maternal age, nulliparity, gestational diabetes, and obesity. Nulliparity was a significant independent predictor of LBW (OR 1.51, CI 1.07, 2.14) in all three groups when controlling for maternal age, gestational diabetes and obesity regardless of fertility conception status. Conclusion: Women with a history of infertility who undergo infertility treatment and conceive a singleton pregnancy are not at increased risk of preterm delivery but may be at increased risk for having a LBW infant.

The purpose of this Grounded Theory study was to explore the reasons for the seemingly underuse of emergency contraceptive pills (ECP) in older adolescent and young adults. Knowledge, attitudes, experiences, partner influence, and couple dynamics as they relate to decision making about ECP use were explored. Observations and interviews were conducted with 22 sexually involved, heterosexual couples with members ranging from 18 to 25 years of age. Basic knowledge of ECP was a requirement but prior use was not. Both individual and couple interviews were conducted with each dyad. Participants revealed several meanings that ECP use held for them based on moral principles, personal responsibility, and the safety and efficacy of ECP. Each of these categories represented a continuum of value judgments. Despite the relatively high educational level of the participants, these ascribed meanings were often based on incomplete or erroneous information. The majority of couples favored ECP use though often in limited circumstances only; within couple concordance on this issue was high. Couple dynamics and decision making about ECP use revealed issues of trust and power, with female participants expressing feelings of control and their partners expressing vulnerability. Theses emotions stemmed from the reality that females could make the final decision about ECP use. Perceived and actual contraceptive responsibility sometimes varied both with individuals and within couples. Implications for practice include more comprehensive health education regarding contraception in general, including ECP, with a concerted effort to including young men in the process. Clinicians need to be aware of popular misconceptions about ECP so that they might provide accurate information. Those practicing with young adult populations also need to be aware that contraceptive decision making does not occur in isolation, but rather often includes a young woman's partner, and therefore, realize the salience of couple dynamics in their approach. Additionally, the results of this study may provide a basis for future theory development regarding ECP decision making in young adult couples.

ABSTRACTProblem: Cardiac surgery is frequently performed in older adults, but little is knownabout the quality of recovery (QoR) during the first postoperative month. Older adults are less likely to regain prior functional status by hospital discharge and temporarypostoperative functional loss may become permanent, adversely affecting QoR. Studyaims were to: examine relationships between pain, wound healing, surgical risk,functional status, mood, quality of life (QoL) and QoR at discharge and 30 days; estimate effects of change over time in functional status, mood and QoL on the change in QoR from discharge to 30 days; describe factors hindering or promoting recovery and the amount of recovery achieved one month after cardiac surgery in older adults.Methods: In this prospective cohort study, functional status, mood, and QoL wereassessed preoperatively, at discharge, and 30 days postoperatively. Wound healing andpain were assessed for five days postoperatively and at 30 days. Surgical risk wasassessed preoperatively. QoR was assessed at discharge and 30 days. A one-monthinterview assessed promoters and inhibitors of recovery, and percentage of achievedrecovery. Non-parametric correlation and multi-level negative binomial regression wereused for analysis.Results: Subjects (n = 62) were mostly male (74.2%) with a mean age of 75.9 (SD 7.01). Preoperative functional status, measured with basic activities of daily living (BADL) and intermediate activities of daily living (IADL), correlated with QoR at discharge (rho =.35, .37) and 30 days (n = 59, rho = .46, .27). Preoperative mood and QoL correlated with QoR at 30 days (rho = -.43, .53). Multi-level models showed significant changes between the variables and QoR over time, with the greatest difference in QoR resulting from the change in IADL. Family support was identified as the most important promoter of recovery and mobility limits as the greatest hindrance, while 62% had perceived recovery levels of 75% at 30-days.Conclusions: Functional status predicts QoR in older cardiac surgery patients. Futureresearch needs to address methods of improving functional status in the firstpostoperative month to improve QoR in older cardiac surgery patients.

Children with cancer experience a myriad of disease or treatment related symptoms. Little is known about the multiple dimensions of these symptoms, how these dimensions change during treatment, and the relationship between symptoms and health related quality of life (HRQOL).The purposes of this study, in a sample of children who underwent myelosuppressive chemotherapy were to: describe changes in symptom occurrence and severity during a course of chemotherapy. In addition, these children's scores on a generic measure of HRQOL were compared to a normative sample of healthy children and relationships between demographic, clinical, and symptom characteristics and generic and disease-specific dimensions of HRQOL were examined in the children with cancer.Children completed the Memorial Symptom Assessment Scale (MSAS), the PedsQL Generic and Cancer Modules, and the Karnofsky Performance Status (KPS) at the start of chemotherapy (T1) and weekly for the next two weeks (T2 and T3). Patients (n=66), were predominantly male (51.5%), minority (62.1%), and 14.9 years of age.The mean number of symptoms per patient was 10.6 at T1, 10.7 at T2, and 8.4 at T3. Using multilevel logistic regression, fatigue, sadness, irritability, worrying, weight loss, and sweating showed a decreasing linear trend. Significant quadratic patterns of change were found for feeling drowsy, nausea, and vomiting. Using multilevel negative binomial regression, no significant differences, over time were found in any of the MSAS symptom severity scores.Compared to the normative sample, children with cancer reported significantly lower total and subscale scores except for emotional and social functioning. No significant differences were found between any demographic characteristics and any total or subscale scores on the generic or disease specific measures of HRQOL. Lower KPS scores were associated with poorer generic and disease specific HRQOL scores. A higher number of symptoms and higher symptom distress scores were associated with poorer generic and disease specific HRQOL scores.Children experienced a high number of symptoms at the initiation of a chemotherapy cycle that persisted over the subsequent two weeks. Among the demographic, clinical, and symptom characteristics studied, poorer functional status and higher symptom burden were associated with significant decreases in HRQOL.

Liver transplantation is the treatment of choice for End Stage Liver Failure patients. The limiting factor in providing liver transplantation is organ availability. Despite the implementation of an acuity based cadaveric liver allocation system in 2002, limited research addresses disparity in access to this scarce resource in this current era of allocation.The primary purpose of this research project was to increase the understanding and the effect of specific predisposing, enabling and need variables in access to liver transplantation by comparing cadaveric transplant recipients to those who continued to wait for a cadaveric liver from February 27, 2002 through November 30, 2007. The study analyzed secondary data from the federally mandated database managed by the Organ Procurement Transplant Network and the United Network of Organ Sharing that included 32,566 patients. The acuity-based model of organ allocation (MELD) adopted in 2002 was used to control for acuity at the time of transplant. Using two sets of Cox Proportional Hazard Regression analyses, time to transplant and potential disparities were evaluated. Because the analysis showed that the likelihood of receiving a cadaveric liver transplant doubled for those with MELD scores greater than or equal to 15 after the implementation of a minimum MELD score rule in 2005, the model used a dummy variable to control for the time period (after the 2005 rule adoption). The regression models found disparities in time to transplant by gender, race, and age, and geographic location controlling for acuity, time period, predisposing, enabling and need variables. Women were found to be 13 percent less likely to receive liver transplants then men. African Americans, Hispanics and Asians were found to be 11, 19 and 16 percent less likely than whites to receive a liver transplant respectively. In addition significant regional differences in hazard of transplant were discovered. There was wide variation in access time across regions with an increased likelihood of transplantation from 11 to102 percent in selected regions. Disparities in gender, race, and payer status were found across UNOS regions as well. These disparities across gender, race and geographical region suggest the need for an evaluation of the federally mandated system of allocation.

AbstractSymptom clusters are stable groups of interrelated symptoms that occur simultaneously. Research on symptom clusters may yield findings that can be used to improve symptom assessment and management. The purposes of this dissertation research were: to evaluate for differences in symptom clusters in a homogeneous sample of oncology patients who underwent radiation therapy (RT) using both the occurrence rates and severity ratings from the Memorial Symptom Assessment Scale (MSAS), as well as to evaluate for differences in symptom factor severity scores between patients with breast and prostate cancer at the end of RT, and to determine the number and types of symptom clusters at three time points (i.e., at the middle of, at the end of, and 1 month after the completion of RT).A sample of 160 patients who underwent RT was evaluated in this study. Patients completed a clinical questionnaire that obtained information on demographic and clinical characteristics, as well as the MSAS that measured the multidimensional experience of symptoms. Exploratory factor analyses of symptoms were done for selected time points. While the specific symptoms within each symptom cluster were not identical, three very similar symptom factors (i.e., "mood-cognitive" symptom cluster, "sickness-behavior" symptom cluster, "treatment-related" symptom cluster) were identified regardless of whether occurrence rates or severity ratings were used to create the symptom clusters at the end of RT. However, the factor solution derived using the severity ratings fit the data better. Significant differences in all three symptom severity scores were found between patients with breast and prostate cancer. For all three symptom factors, the patients with breast cancer had higher symptom severity factor scores than the patients with prostate cancer. Although the number and specific symptoms within each cluster were not identical, three distinct symptom clusters were found across the three time points: "mood-cognitive" symptom cluster, "sickness-behavior" symptom cluster, and "treatment-related" or "pain" symptom cluster. However, differences over time were noted in the "treatment-related" or "pain" symptom clusters. Specifically, at the middle of RT, problem with urination and diarrhea clustered together, while problem with urination and skin problems associated with treatment clustered together at the end of RT. Furthermore, a new symptom cluster (i.e., pain) emerged at 1 month after completion of RT. Future research needs to confirm these findings as well as consider an evaluation of homogeneous samples of patients in terms of both cancer diagnoses and treatments.

ABSTRACTSHARING STORIES:UNDERSTANDING EARLY CHILDBEARING AMONG RESERVATION-BASEDNATIVE AMERICAN WOMENby Janelle F. PalaciosDoctor of Philosophy in NursingUniversity of California, San Francisco, 2008Early child-bearing (ECB), or becoming pregnant at age 18 or younger, is a common and poorly understood event among the Native American population. In 2002 Native American ECB rates of 53.8 per 1,000 live births were higher than total United States ECB rates (42.9/1,000) and White ECB rates (28.6/1,000). In general, regardless of age at childbirth, Native American women have poor maternal/child outcomes compared to other populations, and minimal research has inquired into these women's ECB experiences. This interpretive phenomenological study aimed to discover retrospectively the ECB experiences of adult, self-identified Native American women who lived on a particular reservation located in the Western United States. Specifically, this study sought to understand (a) the social context situating women's ECB experience, and (b) ECB effects on women's life trajectories. The findings revealed that women's childhood contexts situated their entrée into ECB and affected the meanings women ascribed to their experience. Accounts of their childhoods revealed numerous exposures to traumatic events (e.g. parental substance use, neglect, abuse, death, and divorce) which often times contributed to risky behaviors and early pregnancy. Women embodied ECB according to their life situations. For some, ECB extended the chaos from their childhoods and became a challenge as they negotiated roles and responsibilities. Other women took up ECB as a means to heal emotional voids inherited from their youth. Additionally, some women felt their adulthood was confirmed through their mothering role and initiated changes in their lives that enabled them to refrain from engaging in risky behaviors.The theories of Historical Trauma and Weathering are discussed in terms of how they contribute to women's childhoods and how ECB may serve as a protective factor enabling women to discontinue the intergenerational cycle of risk. Implications for health care, future research and clinical practice are presented.

The purpose of this grounded theory study was to explore how nurses in acute care units and an end-of-life facility manage professional and personal boundaries while delivering palliative care to children and families. Pediatric palliative care principles emphasize providing emotional support to children with life-limiting illness and thier family members. Families desire this support during such a vulnerable and intimate experience. Nurses derive satisfaction and see their work as meaningful when they are able to engage and connect with patients and families, but patients' deaths also provoke feelings of grief and a sense of loss. This study asked, "What process(es) do nurses who work in pediatric palliative care use to negotiate boundaries?" It additionally explored how work settings and emotions affect this process.A purposive sample of 18 registered nurses participated and they were recruited from two sites: a children's hospital and a free-standing end-of-life facility. Within the children's hospital, nurses were recruited from the hematology/oncology/ bone marrow transplant unit, the Pediatric Intensive Care Unit, and the Intensive Care Nursery. Participants were interviewed using a semi-structured interview guide and observed in their work setting. Data was analyzed using grounded theory and situational analysis methodologies.Major findings centered on how nurses constructed, perceived, and negotiated boundaries. Findings indicated that the nature of participants' practice required them to actively navigate personal and professional boundaries in order to deliver competent and compassionate care. Although there were identified differences among settings, all participants shared a similar process, maintaining integrity, in navigating boundaries. Nurses worked within an external and internal context which influenced this process and subsequently shaped their nursing practice. Participants described a range of emotions and coping strategies which enabled them to continue practicing in a field which required a level of emotional engagement.The findings contribute to better understanding of how to provide optimal palliative care to children and families. Nurses perceived boundaries as flexible, rather than rigid and they emanated from within nurses, rather than being externally imposed on them. Important practice implications suggest the need to strengthen professional support for nurses in pediatric palliative care through training, education, and ongoing emotional assessments.

Depressive symptoms, sleep disturbance and chronic illness are seldom studied together. Depression is higher in women and insomnia is a common sleep problem for women. Both are nurse-managed symptoms. This dissertation first proposes a theoretical nursing perspective of insomnia guided by four theoretical perspectives. The concepts from these perspectives were incorporated into a proposed model focused on mechanisms of insomnia and insomnia symptom experience.The research involved a community-based sample of 347 healthy, ethnically diverse, premenopausal women between 40-50 years of age. The purpose was to describe patterns of depressive symptoms across time as a function of fixed demographic factors and time-varying biological and social factors, and describe the relationship between depressive symptoms and physical illness. The women with hypertension provided a group with a chronic physical illness.Longitudinal data included the Center for Epidemiologic Studies - Depression (CES-D) scale, investigator-designed questionnaires about sociodemographics, medical history, and health problems, Pittsburgh Sleep Quality Index, social support subscale of the Interpersonal Relationships Inventory, and the health perception item from the Medical Outcomes Study Short Form. Biometric measures included: follicle stimulating hormone assays, blood pressure, and height and weight for calculating body mass index (BMI). Group comparisons used t-tests, ANOVA, chi square, and Mann-Whitney U.Negative binomial regression was used for analysis of CES-D due to its skewed distribution in this sample. A significant model of predictors of CES-D scores was identified. Prevalence of depressive symptoms was 30% at study initiation and 26% at 30 months. Predictors of high CES-D scores were poor sleep quality, presence of chronic illness at 30 months, high BMI, and the interaction of time and poor sleep quality. Time, having a partner, positive social support and the interaction of time with low BMI predicted low CES-D scores. A higher proportion of African American women scored > 16 on the CES-D. Number of health conditions, presence of chronic illness, and hypertension were significantly higher for women scoring >16 on CES-D compared to women scoring

This dissertation considers how families with a child with a life-limiting condition at end-of-life manage the transitions associated with the various locations of care: home, hospice, and hospital. Twenty-five participants were included in this grounded theory study: 9 mothers, 6 fathers, 4 grandmothers, 5 siblings, and one ill child. Families were recruited from either of two agencies: a pediatric hospice facility, or in-home hospice program.Families had little to no support in transitions between locations of care; the transition process to the pediatric hospice facility was marked by a decision-making process that was dependent on the triad of messenger, delivery, and timing. Parents chose a hospice facility only if they had received accurate information from a trusted health care provider at a time when they were ready to consider such an option. The families' complex journey through end-of-life was inextricably tied to the care they received at each location of care.The findings of the study underscore the importance of health care providers' role in parental decision-making, and provide insights into families' experiences from a family perspective. The findings indicate that families needed support in order to maintain family integrity and function; however, such support was rarely found, except through pediatric hospice. In-home hospice services were limited in the support during bereavement; however, the pediatric hospice facility continued to provide support as long as the family desired. The experience at the hospice facility was overwhelmingly positive.The implications for practice include the need to provide guidance during the transitions between locations of care, including supporting families from diagnosis through bereavement, increasing access to information, and improving provider education in EOL care. The implications for research include the need to remove barriers that exclude families with children at EOL as there are few studies that include this population.