Vaccination intention and uptake within the Black community in Appalachia.

OBJECTIVE: Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior. METHOD: Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type. RESULTS: Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12). CONCLUSIONS: These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Education for public health 2030: transformation to meet health needs in a changing world.

Education for public health is at a critical inflection point, and either transforms for success or fails to remain relevant. In 2020, the Association for Schools and Programs of Public Health launched an initiative, Framing the Future 2030: Education for Public Health (FTF 2030) to develop a resilient educational system for public health that promotes scientific inquiry, connects research, education, and practice, eliminates inequities, incorporates anti-racism principles, creates and sustains diverse and inclusive teaching and learning communities, and optimizes systems and resources to prepare graduates who are clearly recognizable for their population health perspectives, knowledge, skills, attitudes, and practices. Three expert panels: (1) Inclusive excellence through an anti-racism lens; (2) Transformative approaches to teaching and learning; and (3) Expanding the reach, visibility, and impact of the field of academic public health are engaged in ongoing deliberations to generate recommendations to implement the necessary change. The article describes the panels' work completed thus far, a "Creating an Inclusive Workspace" guide, and work planned, including questions for self-evaluation, deliberation, and reflection toward actions that support academe in developing a resilient education system for public health, whether beginning or advancing through a process of change. The FTF 2030 steering committee asserts its strong commitment to structural and substantial change that strengthens academic public health as an essential component of a complex socio-political system. Lastly, all are called to join the effort as collaboration is essential to co-develop an educational system for public health that ensures health equity for all people, everywhere.

Racism in oral healthcare settings: Implications for dental care-related fear/anxiety and utilization among Black/African American women in Appalachia.

OBJECTIVE: To explore the association of racism in oral healthcare settings and dental care-related fear/anxiety with dental utilization among Black/African American women in Appalachia. METHODS: We analyzed self-report measures of racism in oral healthcare settings, dental care-related anxiety and fear, recency of a dental visit, and demographic information from 268 pregnant women participating in the Center for Oral Health Research in Appalachia (COHRA) SMILE cohort. All participants self-identified as African American or Black and resided in Appalachia (i.e., either West Virginia or Pittsburgh, PA). RESULTS: Over one-third of the participants reported at least one instance of racism in oral healthcare settings, with "not being listened to" due to their race or color as the most frequent issue (24.4%). Clinically significant levels of dental care-related anxiety and fear were reported by 14.3% of the sample. A mediational model demonstrated that the experience of racism in oral healthcare settings was a significant predictor of dental fear/anxiety, and that dental fear/anxiety was a significant predictor of dental utilization. There was a significant relationship between racism in oral healthcare settings and dental utilization only when mediated by the presence of dental care-related fear and anxiety. CONCLUSIONS: Together, experiences of racism in oral healthcare settings and dental care-related fear/anxiety are predictive of decreased dental utilization for Black/African American women living in Appalachia. This study provides insight into racism in oral healthcare settings as a social determinant of dental anxiety/fear and inequities in dental utilization.

Geographic isolation predicts tobacco product use among youth: A latent class analysis.

PURPOSE: The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents. METHODS: High school students (N = 566) from north-central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health-related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants' geographic rurality and class membership were evaluated using a series of multinomial logistic regressions. FINDINGS: LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users. CONCLUSIONS: The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas.

Cumulative disadvantage as a framework for understanding rural tobacco use disparities.

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural-nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Classic adrenal adenoma undergoing necrosis secondary to chemotherapy for pancreatic adenocarcinoma.

Our patient was a 53-year-old male with borderline resectable pancreatic adenocarcinoma who on his initial staging CT and subsequent MRI was found to have an incidental adrenal adenoma. Following completion of six cycles of neoadjuvant chemotherapy over a three-month period, the patient returned for restaging. The adrenal nodule had increased in size and had undergone necrosis with just a fine cuff of residual viable lesion at the margins. It is thought that chemotherapeutic agents should not lead to significant cell death of an adrenal adenoma, and this produced diagnostic uncertainty. Interestingly, the lesion was subsequently biopsied under CT with histology confirming a classic adrenal adenoma. This rare case challenges our understanding of chemotherapeutic effects on adrenal adenomas, and offers another differential when assessing necrotic adrenal lesions.

A Statement of Commitment to Zero Tolerance of Harassment and Discrimination in Schools and Programs of Public Health.

The Association of Schools and Programs of Public Health convened a Task Force on Zero Tolerance of Harassment and Discrimination in 2019 to develop a policy statement and strategies for addressing harassment of all types in institutions offering public health education. We outline the premises and scholarly foundation for the development of the Statement of Commitment to Zero Tolerance of Harassment and Discrimination, the statement itself, and future plans for realizing the aspiration established in the statement. The development of this living document is predicated on the belief that it is the core responsibility of academic institutions to build the knowledge and that it is the responsibility of leaders, namely deans of schools of public health and directors of public health programs, to lead in building the shared knowledge and insist on the practices that create institutions for a better future free of harassment and discrimination. Our statement is informed by the knowledge that aggressions in the form of harassment and discrimination undermine the health and well-being of individuals, the public, and populations.

Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital.

Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 - 2008) and 9 years after its introduction (2009 - 2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P  < 0.0001), and shorter average LoS (1 vs 9 days, P  < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.

The Casualties Left Behind in Tobacco's Cinders of Combustion.

PURPOSE: This paper 1) defines the scope of tobacco-related health disparities; 2) reviews population-based approaches aimed to eliminate disparities- Medicaid, the U.S. Preventive Health Service Task Force, and the Family Smoking Prevention and Tobacco Control Act; and 3) discusses their potential role in reducing tobacco use and lung cancer disparities. RECENT FINDINGS: The implementation of population-based approaches aimed to reduce tobacco use and chronic diseases has been inequitable. The poor are predominately affected by limited access to comprehensive tobacco cessation coverage. Moreover, lung cancer screenings reveal that those disproportionately excluded are African Americans who have the highest lung cancer incidence and mortality in the United States. The potential impact of the Family Smoking Prevention and Tobacco Control Act is unclear, but the proposed rule to ban menthol combustible and not non-combustible tobacco products could potentially contribute to a cycle of addiction in disadvantaged communities. Alternative solutions, including civil rights litigation, should be investigated. SUMMARY: Eliminating tobacco-related health disparities is a health, social justice, civil rights, and ethical issue that deserves immediate attention and equitable policy solutions.

A Qualitative Approach to Increasing HIV Prevention in Primary Care Settings for Older Adults: Perspectives From Primary Care Providers.

The purpose of this research was to explore primary care providers' willingness and ability to increase HIV prevention efforts among older adults and to gain recommendations for improving HIV prevention in primary care settings. Data were collected through 24 semistructured interviews with primary care providers. The results of the study reveal that the majority of providers find it necessary to increase HIV prevention efforts in primary care settings and are willing to do so; however, they cannot do so without assistance. Providers suggested strategies to increase HIV prevention in primary care, for instance, expanding the use of electronic reminders to include HIV prevention and increasing collaboration among providers of different specialties. As a result of the interviews, additional recommendations for increasing HIV prevention have been identified. These findings will aid in improving the quality of care provided to individuals older than 50 in primary care settings.

Sugar and Aldehyde Content in Flavored Electronic Cigarette Liquids.

Introduction: Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66). Methods: Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fisher's exact test, and Pearson's correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations. Results: Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose. Conclusions: Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity. Implications: The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDA's interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.

Why We Must Continue to Investigate Menthol's Role in the African American Smoking Paradox.

BACKGROUND: The disproportionate burden of tobacco use among African Americans is largely unexplained. The unexplained disparities, referred to as the African American smoking paradox, includes several phenomena. Despite their social disadvantage, African American youth have lower smoking prevalence rates, initiate smoking at older ages, and during adulthood, smoking rates are comparable to whites. Smoking frequency and intensity among African American youth and adults are lower compared to whites and American Indian and Alaska Natives, but tobacco-caused morbidity and mortality rates are disproportionately higher. Disease prediction models have not explained disease causal pathways in African Americans. It has been hypothesized that menthol cigarette smoking, which is disproportionately high among African Americans, may help to explain several components of the African American smoking paradox. PURPOSE: This article provides an overview of the potential role that menthol plays in the African American smoking paradox. We also discuss the research needed to better understand this unresolved puzzle. METHODS: We examined prior synthesis reports and reviewed the literature in PubMed on the menthol compound and menthol cigarette smoking in African Americans. RESULTS: The pharmacological and physiological effects of menthol and their interaction with biological and genetic factors may indirectly contribute to the disproportionate burden of cigarette use and diseases among African Americans. CONCLUSIONS: Future studies that examine taste sensitivity, the menthol compound, and their effects on smoking and chronic disease would provide valuable information on how to reduce the tobacco burden among African Americans. IMPLICATIONS: Our study highlights four counterintuitive observations related to the smoking risk profiles and chronic disease outcomes among African Americans. The extant literature provides strong evidence of their existence and shows that long-standing paradoxes have been largely unaffected by changes in the social environment. African Americans smoke menthols disproportionately, and menthol's role in the African American smoking paradox has not been thoroughly explored. We propose discrete hypotheses that will help to explain the phenomena and encourage researchers to empirically test menthol's role in smoking initiation, transitions to regular smoking and chronic disease outcomes in African Americans.

Primary Care Providers' HIV Prevention Practices Among Older Adults.

PURPOSE: To explore primary care providers' HIV prevention practices for older adults. Primary care providers' perceptions and awareness were explored to understand factors that affect their provision of HIV prevention materials and HIV screening for older adults. DESIGN AND METHOD: Data were collected through 24 semistructured interviews with primary care providers (i.e., physicians, physician assistants, and nurse practitioners) who see patients older than 50 years. RESULTS: Results reveal facilitators and barriers of HIV prevention for older adults among primary care providers and understanding of providers' HIV prevention practices and behaviors. Individual, patient, institutional, and societal factors influenced HIV prevention practices among participants, for example, provider training and work experience, lack of time, discomfort in discussing HIV/AIDS with older adults, stigma, and ageism were contributing factors. Furthermore, factors specific to primary and secondary HIV prevention were identified, for instance, the presence of sexually transmitted infections influenced providers' secondary prevention practices. IMPLICATIONS: HIV disease, while preventable, is increasing among older adults. These findings inform future research and interventions aimed at increasing HIV prevention practices in primary care settings for patients older than 50.

Nicotine Metabolism in Young Adult Daily Menthol and Nonmenthol Smokers.

INTRODUCTION: Menthol cigarette smoking may increase the risk for tobacco smoke exposure and inhibit nicotine metabolism in the liver. Nicotine metabolism is primarily mediated by the enzyme CYP2A6 and the nicotine metabolite ratio (NMR = trans 3' hydroxycotinine/cotinine) is a phenotypic proxy for CYP2A6 activity. No studies have examined differences in this biomarker among young adult daily menthol and nonmenthol smokers. This study compares biomarkers of tobacco smoke exposure among young adult daily menthol and nonmenthol smokers. METHODS: Saliva cotinine and carbon monoxide were measured in a multiethnic sample of daily smokers aged 18-35 (n = 186). Nicotine, cotinine, the cotinine/cigarette per day ratio, trans 3' hydroxycotinine, the NMR, and expired carbon monoxide were compared. RESULTS: The geometric means for nicotine, cotinine, and the cotinine/cigarette per day ratio did not significantly differ between menthol and nonmenthol smokers. The NMR was significantly lower among menthol compared with nonmenthol smokers after adjusting for race/ethnicity, gender, body mass index, and cigarette smoked per day (0.19 vs. 0.24, P = .03). White menthol smokers had significantly higher cotinine/cigarettes per day ratio than white nonmenthol smokers in the adjusted model. White menthol smokers had a lower NMR in the unadjusted model (0.24 vs. 0.31, P = .05) and the differences remained marginally significant in the adjusted model (0.28 vs. 0.34, P = .06). We did not observe these differences in Native Hawaiians and Filipinos. CONCLUSIONS: Young adult daily menthol smokers have slower rates of nicotine metabolism than nonmenthol smokers. Studies are needed to determine the utility of this biomarker for smoking cessation treatment assignments.

Three Positive Parenting Practices and Their Correlation with Risk of Childhood Developmental, Social, or Behavioral Delays: An Analysis of the National Survey of Children's Health.

OBJECTIVES: (1) Investigate the relationship between three specific positive parenting practices (PPP)-reading to children, engaging in storytelling or singing, and eating meals together as a family-and parent-reported risk of developmental, behavioral, or social delays among children between the ages of 1-5 years in the US. (2) Determine if a combination of these parenting practices has an effect on the outcome. METHODS: Chi square and multiple logistic regression analyses were used to analyze cross-sectional data from the National Survey of Children's Health 2011/2012 in regards to the relationship between each of the three individual PPP as well as a total PPP score and the child's risk of being developmentally, socially, or behaviorally delayed (N = 21,527). Risk of delay was calculated using the Parents' Evaluation of Developmental Status Questionnaire, which is a parental self-report measure that has been correlated with diagnosed child delays. These analyses controlled for poverty and parental education. All analyses were completed using SAS Version 9.3. RESULTS: A strong correlation was found between each of the three PPP as well as the total PPP score and the child's risk of developmental, social, or behavioral delays (p < 0.05 for each test). These associations were found to have a dose-response relationship (p < 0.05 in all but one analysis). CONCLUSIONS: Daily engagement in PPP could possibly reduce children's risk of delay, and specifically engaging in all three PPP may have greater benefit.

Biomarkers of tobacco smoke exposure in racial/ethnic groups at high risk for lung cancer.

OBJECTIVES: We examined biomarkers of tobacco smoke exposure among Native Hawaiians, Filipinos, and Whites, groups that have different lung cancer risk. METHODS: We collected survey data and height, weight, saliva, and carbon monoxide (CO) levels from a sample of daily smokers aged 18-35 (n = 179). Mean measures of nicotine, cotinine, cotinine/cigarettes per day ratio, trans 3' hydroxycotinine, the nicotine metabolite ratio (NMR), and expired CO were compared among racial/ethnic groups. RESULTS: The geometric means for cotinine, the cotinine/cigarettes per day ratio, and CO did not significantly differ among racial/ethnic groups in the adjusted models. After adjusting for gender, body mass index, menthol smoking, Hispanic ethnicity, and number of cigarettes smoked per day, the NMR was significantly higher among Whites than among Native Hawaiians and Filipinos (NMR = 0.33, 0.20, 0.19, P ≤ .001). The NMR increased with increasing White parental ancestry. The NMR was not significantly correlated with social-environmental stressors. CONCLUSIONS: Racial/ethnic groups with higher rates of lung cancer had slower nicotine metabolism than Whites. The complex relationship between lung cancer risk and nicotine metabolism among racial/ethnic groups needs further clarification.

Menthol cigarette smoking and obesity in young adult daily smokers in Hawaii.

This study investigates 1) the relationship between menthol cigarette smoking and obesity and 2) the association of body mass index with the nicotine metabolite ratio among menthol and non-menthol daily smokers aged 18-35 (n = 175). A brief survey on smoking and measures of height and weight, carbon monoxide, and saliva samples were collected from participants from May to December 2013 in Honolulu, Hawaii. Multiple regression was used to estimate differences in body mass index among menthol and non-menthol smokers and the association of menthol smoking with obesity. We calculated the log of the nicotine metabolite ratio to examine differences in the nicotine metabolite ratio among normal, overweight, and obese smokers. Sixty-eight percent of smokers used menthol cigarettes. Results showed that 62% of normal, 54% of overweight, and 91% of obese smokers used menthol cigarettes (p = .000). The mean body mass index was significantly higher among menthol compared with non-menthol smokers (29.4 versus 24.5, p = .000). After controlling for gender, marital status, educational attainment, employment status, and race/ethnicity, menthol smokers were more than 3 times as likely as non-menthol smokers to be obese (p = .04). The nicotine metabolite ratio was significantly lower for overweight menthol smokers compared with non-menthol smokers (.16 versus .26, p = .02) in the unadjusted model, but was not significant after adjusting for the covariates. Consistent with prior studies, our data show that menthol smokers are more likely to be obese compared with non-menthol smokers. Future studies are needed to determine how flavored tobacco products influence obesity among smokers.

Internal medicine interns' and residents' pressure ulcer prevention and assessment attitudes and abilities: results of an exploratory study .

 To evaluate and determine differences between attitudes of internal medicine interns and residents toward pressure ulcer (PU) prevention and to evaluate the interns' abilities to accurately identify wounds and stage PUs, an exploratory, quantitative study was conducted in a 639-bed, safety net academic center. Participants (21 internal medicine interns and 21 internal medicine residents) attending an educational session on PU prevention and care were eligible to participate. The 1-hour conference session was prepared and provided by a physician and wound care nurses. Before the lecture, participants were asked to complete an 11-question paper-and-pencil PU attitude survey. Following the lecture, they were asked to identify 11 wounds and stage PUs using the inpatient admission history and physical template used in the hospital's electronic medical record. An audience response system was used to record correct and incorrect responses. Nineteen (19) interns and 20 residents completed the survey. Twenty-one (21) interns successfully completed the wound assessment quiz. Descriptive statistics were used to examine the survey data and residents' and interns' average attitude scores were compared using independent group t-test. The results suggest that interns and residents have a positive attitude toward and are concerned about PU prevention. The significantly higher overall score among interns compared to residents (average 43.8 versus 38.8 respectively, P = 0.002) suggests interns have a more positive attitude than residents. Statistically significant differences between item scores showed that, compared to residents, interns perceived PU prevention to be more time-consuming (P = 0.01), less of a concern in practice (P = 0.02), and a lower priority than other areas of care (P = 0.003). Compared to residents, interns also were more likely to agree to with statement, "In my opinion, patients tend to not get as many pressure ulcers nowadays" (P = 0.0006). Both groups agreed that PU prevention is a greater priority than treatment and that using risk assessment tools is better than relying on clinical judgment. Wound assessment and PU staging results varied greatly, ranging from 100% for correct staging of a Stage I PU to 20% correct staging of an unstageable PU and 3% correct identification of a diabetic foot ulcer. Overall, internal medicine interns and residents have a favorable attitude toward PU prevention. Despite the limitations of this study, results suggest that enhanced medical school and residency wound care curricula are needed.