Risk of depression in pregnant women with low-normal serum Vitamin B12.

High prevalence rates of both Vitamin B12 insufficiency and depressive symptoms exist in pregnant women. Although the association between depressive symptoms and certain nutrient deficiencies like iron, folate, or Vitamin B12 has been established, the specific relationship between low-normal serum Vitamin B12 levels and depressive symptoms in pregnant women in the United States has not been studied closely. Using 2005-2006 National Health and Nutrition Examination Survey data, a secondary analysis was conducted to examine the association between low-normal serum Vitamin B12 level and depression, as measured by a score of 10 or higher on the Patient Health Questionnaire-9, in pregnant women (N = 174). In bivariate regression models, Vitamin B12 level, experiencing poverty, and pre-pregnancy body mass index (BMI) were significant predictors of depression. In multivariate logistic regression models, pregnant women with low-normal serum Vitamin B12 levels (OR = 3.82, 95% CI [1.10-13.31], p < 0.04) were 3.82 times more likely to experience depression, controlling for sociodemographic characteristics, pre-pregnancy BMI, and the biomarkers hemoglobin and folate. Identifying and treating pregnant women with low-normal Vitamin B12 levels may enhance prenatal depression management.

Self-rated health among American adolescents with type 1 diabetes in the T1D Exchange Clinic Registry.

BACKGROUND: The goal of this study was to examine the self-rated health (SRH) of adolescents with type 1 diabetes (T1D). METHODS: A logistic regression analysis of baseline data from adolescents in the United States included in the T1D Exchange Clinic Registry in 2010-2012 was conducted. Participants were 13-18years old at the time of enrollment in the registry and had been diagnosed with T1D at least one year before enrollment (n=5799). RESULTS: Half (49.0%) of the participants were female, 46.3% were ages 16-18years, 22.5% were non-white, 35.7% did not have private/military health insurance, and 78.8% had HbA1c levels >7.5%, indicating poor T1D management, 20.7% reported having diabetes-related stress often or very often, and 46.4% used insulin injections or pens rather than a pump. In total, 10.3% (n=600) of the participants rated their health as poor or fair and 59.3% (n=3439) rated their health as very good or excellent. Participants with poor or fair SRH were more likely than those with very good or excellent SRH to be female (adjusted OR=1.7(1.4, 2.1)), 16 to 18years old (OR=2.1(1.7, 2.5)), and non-white (OR=2.7(2.2, 3.4)), to be without private or military insurance (OR=2.4(2.1, 3.0)), to have HbA1c levels >7.5% (OR=3.3(2.4, 4.7)), to report having diabetes-related stress often or very often (OR=6.1(5.1, 7.2)), and to use an injection or pen rather than a pump (OR=2.1(1.6, 2.4)). CONCLUSIONS: Because adolescents with T1D who report lower SRH are more likely to have uncontrolled blood glucose and frequent diabetes-related stress, use of pumps and stress-reduction strategies may improve SRH among adolescents with T1D.

Findings From a Pilot Study: Bringing Evidence-Based Practice to the Bedside.

BACKGROUND: To translate research supporting inpatient care outcomes and provide evidence-based care, registered nurses (RNs) need continuing education and mentoring support to adopt evidence-based practice (EBP). AIMS: The aim of this study was to assess a demonstration project intended to pilot and evaluate a structured EBP education with mentoring innovation for nurses in a multihospital system. METHODS: Nurses from five units in five hospitals were included in an education with mentoring innovation to implement the Johns Hopkins Nursing Evidence-Based Practice Model and the Advancing Research and Clinical practice through close Collaboration (ARCC) Model. To determine outcomes, the EBP beliefs scale (EBPB) and implementation scale (EBPI) were administered before and after the education with mentoring innovation. Eighty-three RNs completed both preintervention surveys. A total of 57 RNs completed the postintervention surveys. In addition, qualitative data were obtained from focus groups involving 24 participants. FINDINGS: Statistical analysis indicated positive movement toward EBP in project participants. Qualitative analysis revealed perceived successes and challenges involved with implementing an evidence-based program, provided logistical lessons learned, and indicated that nurses at all levels of practice require mentoring and coaching to foster EBP sustainment. LINKING EVIDENCE TO ACTION: The engagement of nurses in this project supported professional development and clinical application of evidence at the point of care. The pilot project's outcome informed a decision by health system administrators to fund more nurse driven EBP projects in the five hospitals. This innovative program provides a replicable structure for deployment and appraisal of EBP nursing model implementation.

Enhancing Patient Safety: Factors Influencing Medical Error Recovery Among Medical-Surgical Nurses

Keeping patients safe is a core nursing duty. The dynamic nature of the healthcare environment requires that nurses practice to the full extent of their education, experience, and role to keep patients safe. Research has focused on error causation rather than error recovery, a process that occurs before patient harm ensues. In addition, little is known about the role nurses play in error recovery. A descriptive cross-sectional, correlational study using a sample of 184 nurses examined relationships between nurse characteristics, organizational factors, and recovery of medical errors among medical-surgical nurses in hospitals. In this article, we provide background information to introduce the concept of error recovery, and present our study aims and methods. Study results suggested that medical-surgical nurses recovered on average 22 medical errors and error recovery was positively associated with education and expertise. The discussion section further considers the important role of medical-surgical nurses and error recovery to enhance patient safety. In conclusion, we suggest that creating a safer healthcare system will depend on the ability of nurses to fully use their education, expertise and role to identify, interrupt, and correct medical errors; thereby, preventing patient harm.

Evaluating Diabetes Educational Interventions With a Skill Development Component in Adolescents With Type 1 Diabetes: A Systematic Review Focusing on Quality of Life.

PURPOSE: Adolescents with type 1 diabetes mellitus (T1DM) may have reduced quality of life (QOL) when compared with their peers. This systematic review evaluated the effectiveness of diabetes self-management education (DSME) interventions with a skills development component on the QOL of adolescents with T1DM. METHODS: Six databases were systematically searched for studies on the QOL outcomes of DSME interventions for adolescents with T1DM. Fourteen studies published between 1994 and 2014 met the inclusion criteria. RESULTS: Of the 14 studies, only 4 had significant QOL outcomes for the intervention participants. Successful DSME interventions had indirect behavioral skills foci or a combination of indirect and direct behavioral skills foci and a duration ≥2 months. CONCLUSION: This review provides evidence that educational interventions with an indirect behavioral skills development that facilitates diabetes management may improve QOL among adolescents with T1DM. Structured interventions targeting adolescents' QOL are needed to determine which are most effective in improving QOL. Adolescents with T1DM should be routinely screened and monitored for low QOL and referred to QOL-improving interventions.

Nurses' role in medical error recovery: an integrative review.

AIMS AND OBJECTIVES: The aim of this study was to conduct an integrative review of the literature to fully understand nurses' role in medical error recovery. BACKGROUND: Despite focused efforts on error prevention, the prevalence of medical errors occurring in the health care system remains a concern. Patient harm can be reduced or prevented by adequate recovery processes that include identifying, interrupting and correcting medical errors in a timely fashion. Both medical error prevention and recovery are critical components in advancing patient safety, yet little is known about nurses' role in medical error recovery. DESIGN: An integrative review of the literature, guided by Whittmore and Knafl's (Journal of Advanced Nursing, 5, 2005, 546) five-step process, was conducted for the period between 2000-2015. A comprehensive search yielded twelve articles for this review. METHODS: The level and quality of evidence of the included articles was rated using a five-level rating system and the Johns Hopkins Nursing Quality of Evidence Appraisal developed by ©The Johns Hopkins Hospital/The Johns Hopkins University. RESULTS: The medical error recovery rate varied across specialty nursing populations with nurses recovering, on average, as many as one error per shift to as few as one error per week. Nurses rely on knowing the patient, environment and plan of care to aid in medical error recovery. CONCLUSIONS: Nurses play a unique yet invisible role in identifying, interrupting and recovering medical errors. Individual and organisational factors influencing nurses' ability to recover medical errors remain unclear. RELEVANCE TO CLINICAL PRACTICE: Greater understanding of nurse characteristics and organisational factors that influence error recovery can foster the development of effective strategies to detect and correct medical errors and enable organisations to reduce negative outcomes.

Costs related to promoting breastfeeding among urban low-income women.

OBJECTIVE: To describe the costs of providing support to breastfeeding low-income women and compares costs to cost offsets of the intervention. DESIGN: Secondary analysis of data from a randomized controlled trial of an intervention to promote breastfeeding among low-income women with full-term infants. SETTING: A university hospital and a community hospital in Baltimore, Maryland. PARTICIPANTS: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligible breastfeeding women (N = 328) were randomized to usual care or the community health nurse/peer counselor intervention. METHODS: The researchers collected and described personnel and mileage costs over the entire duration of the intervention (24 weeks). Researchers also compared (using t tests) change in resources associated with breastfeeding including the number of clinic visits, hospital nights, emergency room visits, prescriptions, and formula feedings per day up to 12 weeks. RESULTS: The cost of the personnel and travel required for the intervention was $296 per woman. The use of medical care and number of formula feedings per day were similar for the intervention and usual care groups. When differences in use of medical care and formula feeding were statistically significant, the intervention group used fewer resources. CONCLUSION: Support for breastfeeding by community health nurses and peer counselors is partially offset by reducing medical care utilization and formula feeding costs.

African American and Latino patient versus provider perceptions of determinants of prenatal care initiation.

Few studies have compared provider and patient perceptions of barriers, motivators and facilitators of prenatal care (PNC) initiation. The current study compared these perceptions in providers and patients in Washington, DC, a city characterized by infant mortality and low birth weight rates that are among the highest in the nation, and poor utilization of PNC, particularly among minority groups. The results reported here were part of a larger study of barriers, motivators and facilitators influencing PNC utilization in Washington, DC. A convenience sample of 331 African American and Latino patients and 61 providers were interviewed to identify which of 63 motivators, facilitators, and barriers significantly influenced PNC initiation. Both sample groups were recruited at 14 PNC facilities, selected to represent all sites in DC known to serve high-risk, low-income minority women, including hospital-based clinics, community-based clinics, and private practices. Data were analyzed using Fisher exact tests and Kendall's concordance tests. Results indicated that there was good agreement between patients and providers about the relative importance of the various barriers (especially psychosocial), motivators, and facilitators. However, differences were found between patients and providers in the response frequencies. Providers were more likely to report barriers while patients were more likely to report certain motivators (especially learning better health habits and how to protect health). These results indicate that despite widespread agreement on most issues, especially psychosocial barriers, patients rated health education higher than providers.

Efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers.

Adolescent mothers in Washington, DC have a high rate of subsequent teen pregnancies, often within 24 months. Children of teen mothers are at risk for adverse psychosocial outcomes. When adolescents are strongly attached to parents, schools, and positive peers, they may be less likely to repeat a pregnancy. This study tested the efficacy of a counseling intervention delivered by cell phone and focused on postponing subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, and positive youth assets. The objective of this study was to compare time to a repeat pregnancy between the intervention and usual care groups, and, secondarily, to determine whether treatment intensity influenced time to subsequent conception. Primiparous pregnant teens ages 15-19, were recruited in Washington, DC. Of 849 teens screened, 29.3% (n = 249) met inclusion criteria, consented to participate, and completed baseline measures. They were then randomized to the intervention (N = 124) or to usual care (N = 125). Intervention group teens received cell phones for 18 months of counseling sessions, and quarterly group sessions. Follow-up measures assessed subsequent pregnancy through 24 months post-delivery. A survival analysis compared time to subsequent conception in the two treatment groups. Additional models examined the effect of treatment intensity. By 24 months, 31% of the intervention and 36% of usual care group teens had a subsequent pregnancy. Group differences were not statistically significant in intent-to-treat analysis. Because there was variability in the degree of exposure of teens to the curriculum, a survival analysis accounting for treatment intensity was performed and a significant interaction with age was detected. Participants who were aged 15-17 years at delivery showed a significant reduction in subsequent pregnancy with increased levels of intervention exposure (P < 0.01), but not those ≥ 18 years. Adolescents ≥ 18 years faced considerable challenges to treatment success. Individual, social, and contextual factors are all important to consider in the prevention of repeat teen pregnancy. Cell phone-based approaches to counseling may not be the most ideal for addressing complex, socially-mediated behaviors such as this, except for selective subgroups. A lack of resources within the community for older teens may interfere with program success.

A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers.

OBJECTIVE: The purpose of this study was to assess whether providing a breastfeeding support team results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers. DESIGN: A randomized controlled trial with mother-infant dyads recruited from 2 urban hospitals. PARTICIPANTS: Breastfeeding mothers of full-term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (n=328) were randomized to intervention (n=168) or usual-care group (n=160). INTERVENTION: The 24-week intervention included hospital visits by a breastfeeding support team, home visits, telephone support, and 24-hour pager access. The usual-care group received standard care. OUTCOME MEASURE: Breastfeeding status was assessed by self-report at 6, 12, and 24 weeks postpartum. RESULTS: There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared with the usual-care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs 56.9% (odds ratio, 1.71; 95% confidence interval, 1.07-2.76). The difference in rates at 12 weeks postpartum, 49.4% vs 40.6%, and 24 weeks postpartum, 29.2% vs 28.1%, were not statistically significant. CONCLUSIONS: The intervention group was more likely to be breastfeeding at 6 weeks postpartum compared with the usual-care group, a time that coincided with the most intensive part of the intervention.

How motivation influences breastfeeding duration among low-income women.

In-depth interviews were conducted with 44 low-income breastfeeding women to explore the incentives and disincentives to breastfeeding experienced within 6 months postpartum. Using an individual net benefit maximization (INBM) framework based on economic theory, we assessed women's motivations, incentives, and disincentives for breastfeeding. Based on the framework and their experience breastfeeding, women fell into 3 groups: intrinsically motivated, extrinsically motivated, and successfully experienced with both intrinsic and extrinsic motivation. Successfully experienced women were most likely to breastfeed to 6 months. Intrinsically motivated women valued breastfeeding but often required information and instruction to reach breastfeeding goals. Extrinsically motivated women were least likely to continue breastfeeding even with support and instruction. Providers can screen women to determine their experience and motivation then tailor interventions accordingly. Intrinsically motivated women may need support and instruction, extrinsically motivated women may benefit from motivational interviewing, and successfully experienced women may need only minimal breastfeeding counseling.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women.

BACKGROUND: African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format. METHODS: Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported. RESULTS: Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended > or = 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed. CONCLUSION: While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

Determinants of inadequate prenatal care utilization by African American women.

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).

Nurse-supported breastfeeding promotion: a framework for economic evaluation.

Increasingly, economic evaluation results are considered by policymakers, although few nurse-led interventions have undergone such an evaluation. Nurse-supported breastfeeding promotion is used as an exemplar to illustrate economic evaluation. Past work is critiqued and lessons learned are described.

Determinants of late prenatal care initiation by African American women in Washington, DC.

OBJECTIVES: The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC. METHODS: DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation. RESULTS: Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women consideringabortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions. CONCLUSIONS: The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.

Perceptions about prenatal care: views of urban vulnerable groups.

BACKGROUND: In the United States, infant mortality rates remain more than twice as high for African Americans as compared to other racial groups. Lack of adherence to prenatal care schedules in vulnerable, hard to reach, urban, poor women is associated with high infant mortality, particularly for women who abuse substances, are homeless, or live in communities having high poverty and high infant mortality. This issue is of concern to the women, their partners, and members of their communities. Because they are not part of the system, these womens' views are often not included in other studies. METHODS: This qualitative study used focus groups with four distinct categories of people, to collect observations about prenatal care from various perspectives. The 169 subjects included homeless women; women with current or history of substance abuse; significant others of homeless women; and residents of a community with high infant mortality and poverty indices, and low incidence of adequate prenatal care. A process of coding and recoding using Ethnograph and counting ensured reliability and validity of the process of theme identification. RESULTS: Barriers and motivators to prenatal care were identified in focus groups. Pervasive issues identified were drug lifestyle, negative attitudes of health care providers and staff, and non-inclusion of male partners in the prenatal experience. CONCLUSIONS: Designing prenatal care relevant to vulnerable women in urban communities takes creativity, thoughtfulness, and sensitivity. System changes recommended include increased attention to substance abuse treatment/prenatal care interaction, focus on provider/staff attitudes, and commitment to inclusion of male partners.

Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women.

BACKGROUND: Breastfeeding can ameliorate some of the complex health issues faced by low-income families. Women who breastfeed and their infants have lower health care costs compared with those who formula feed. Increasing the duration of breastfeeding is recognized as a national priority, particularly for low-income women. This community-based randomized clinical trial involving low-income mothers compared usual care with an intervention comprising hospital and home visits, and telephone support by a community health nurse/peer counselor team for 6 months after delivery. METHODS: Forty-one women were recruited after delivery of a full-term singleton infant and randomly assigned to intervention or usual care groups. RESULTS: Women receiving the community health intervention breastfed longer than the women receiving usual care. The infants in the intervention group had fewer sick visits and reported use of fewer medications than infants in the usual care group. The intervention cost ($301/mother) was partially offset by cost savings on formula and health care. CONCLUSIONS: Community health nurse and peer counselor support can increase breastfeeding duration in low-income women, and has the potential to reduce total costs including the cost of support.