Reducing patient readmissions within 30 days of an initial hospitalization is fiscally responsible and important to patient-centered care. Home health (HH) agencies, have been publicly reported by Medicare on 30-day readmission to the hospital from HH since 2015, and are proposed to be measured on potentially preventable 30-day post-discharge readmissions in 2019. The body of 30-day readmissions evidence inclusive of HH is small and inconsistent, comprised in part from national claims data or federal-level reports. We cannot assume that while the hospital and HH settings share the same patients that the risks, determinants of readmission and preventative interventions are also the same, nor that Medicare-specific data reports the full story. This study was performed as a dissertation, and retrospective, secondary analysis of electronic health record data, aimed at determining HH operations predictors influencing readmission to the hospital during HH services in one northern California HH agency. Logistic regression was used to determine univariate and multiple predictors of two readmission models: 30-day readmission to the hospital during HH services and readmission to the hospital at any time during HH services. Univariate results with 30-day readmission produced 8 significant predictors which were then entered into the 30-day readmission multiple logistic regression (MLR) model simultaneously (omnibus test chi-square 32.058, p=0.000). Two variables continued to demonstrate unique contribution to the model: frontloaded contacts rate in the first week (AOR = 0.970, p = 0.005) and number of high-risk medications (AOR = 1.638, p = 0.027). Univariate results with readmission at anytime produced six significant predictors which were then entered simultaneously to the readmission at anytime MLR model (omnibus test chi-square 29.565, p=0.000). Two variables continued to demonstrate unique contribution to the model: homebound status by medical contraindication (AOR = 5.058, p = 0.011) and HH total length of stay (days) (AOR=1.034, p=0.033). Both the 30-day and anytime readmission models described a unique combination of significant predictors of readmission to the hospital during HH services. This study also defined a manner of calculating frontloaded contacts in the first week of care, which contributed to the 30-day readmission model, bearing operational interest to HH settings.

Regular physical activity has many important health benefits. However, reproductive age mothers are at higher risk for physical inactivity and lower levels of moderate-vigorous physical activity. Personal, social, and environmental correlates of housework/caregiving, occupation, active living, and sports/exercise physical activity were examined among reproductive age mothers. Factors situated on three socioenvironmental levels were theorized to influence physical activity. The individual/intrapersonal level included sociodemographic characteristics and self-efficacy for physical activity. The social/interpersonal level included social norms and social support. The community level included neighborhood environment.

Influence of the different correlates varied among the types of physical activity. Population and income were associated with occupational and sports/exercise physical activity. Relevance of self-efficacy and social support to reproductive age mothers' physical activity were somewhat supported, particularly for sports/exercise physical activity. Social norms navigation, but not social norms, was associated with mothers' sports/exercise physical activity. Aspects of the neighborhood environment were influential in housework/caregiving, occupation, and sports/exercise physical activity.

Social Determinants of Health-related Quality of Life in Palestinian Refugees Living Inside and Outside Camps in Jordan

Background: Palestinian refugees are the world’s largest and one of its longest standing refugee caseloads. Since 1948, Jordan has received several waves of Palestinian refugees who, with their descendants, count for half Jordan’s population. There is a clear concentration of poverty, household crowdedness, inferior housing standards, and limited healthcare and other services access inside camps, in which 18% of Jordan’s Palestinian refugees reside. The Health-related Quality of Life (HRQOL) is the product of not only individuals’ characteristics, but also the characteristics of the surrounding physical and sociopolitical environment.

Objective: Within the context of an integrated HRQOL ecological framework, the dissertation purpose was to (1) describe the state of and gaps in health and social outcomes of Palestinian refugees in Jordan; (2) describe HRQOL, depression and hopefulness to return to Palestine, taking into consideration the influence of age, gender, education and poverty; and (3) compare HRQOL between Palestinian refugees who live inside and outside camps in Jordan, taking into consideration sociodemographic characteristics.

Method: The sample of 177 adult Palestinian refugees living in Jordan was recruited from inside of UNRWA’s Al-Baqa’a Palestinian refugee camp (n = 86) and outside of the camp from surrounding communities in Abu Nsair (n = 91). Participants provided sociodemographic information and completed the World Health Organization QOL Brief Questionnaire.

Results: Palestinian refugees living in Jordan were depressed and nearly half experienced low HRQOL, particularly if refugees were older and poorer. Participants were ‘very hopeful’ about returning to Palestine in the future. Hopefulness, however, was not significantly associated with HRQOL or depression. Furthermore, refugees living inside and outside of camps in Jordan were significantly different by education, type of health insurance and poverty. Physical health, environment and overall HRQOL were significantly higher for non-camp refugees than camp refugees. Regression analyses indicate poverty and residency, individually and/or in combination, were significant predictors of environment, physical health and social relationships HRQOL.

Conclusion: Palestinian refugees in Jordan, especially those who lived inside camps, reported poor HRQOL. Community/public health programs and social policies need to be bolstered or created and implemented to benefit Palestinian refugees in Jordan, particularly inside camps.

ABSTRACT

Influence of Adverse Childhood Experiences, Behavioral and Emotional Functioning and Social Context on Social Competence in the Foster Care Youth Population

Rasheda D’Amber Jones

As compared to the general youth population, foster care youth are particularly vulnerable because of the number and chronicity of adverse childhood experiences (ACEs), which have been associated with emotional and behavioral functioning. Social competence is believed to be the single most predictor of successful transition from adolescence to adulthood. Yet, little is known about social competence, a protective mechanism for adolescent development and adult maturity, in foster care youth. Within the context of the Affective Social Competence model, the two specific aims of this descriptive, correlational cross-sectional study were to describe social competence, emotional and behavioral functioning and ACEs of youth in foster care, taking into consideration their sociodemographic characteristics and the foster care context, and explore the relationship between youth’s social competence and ACEs, emotional and behavioral functioning, sociodemographic characteristics and the foster care context.

The sample of 136 foster care youth was recruited from the San Francisco Bay Area Court Appointed Special Advocate Association. Youth completed the Interpersonal Competence Scale. Their Court Appointed Special Advocate completed the Child Behavior Checklist to assess youth’s emotional and behavioral functioning, report youth’s ACEs and provide information about youth’s sociodemographic characteristics and foster care context. Results indicate youth experienced two to three ACEs, scored slightly above the standardized norms for emotional and behavioral functioning, and had a moderate level of social competence, neither deficient nor exceptional. Latino youth had significantly more emotional and behavioral problems and White and female youth had significantly lower social competence.

Regression analysis suggests social competence was significantly related to youth’s sociodemographic characteristics, but not to their personal experiences nor the foster care context. Youth who were younger, male and African American had significantly better social competence. Sociodemographic distinctions appear to inform youth’s social competence. A tailored approach as opposed to a one-size approach may be a more precise method to improve social competence in the foster care youth population. Adolescent, school and public/community health nurses need to assess youth early in the foster care process in order to create a social competence profile that can be assessed over time as they transition from adolescence to adulthood.

ABSTRACT

The representation of racial and ethnic minorities in the nursing workforce is disproportionately low in comparison with their representation in the general population in the United States. Despite diversity initiatives, the slight increase in enrollment of under-represented minority (URM) students in graduate schools of nursing at predominantly White universities (PWU) has not resulted in a significantly more diverse nursing workforce. The purpose of the study was threefold: (a) to describe the pre-admission personal backgrounds and pre-entry decision-making processes of URM students in doctoral nursing programs at PWUs, (b) to describe the processes of academic socialization and progression experienced by URM students in doctoral nursing programs at PWUs, and (c) to describe the availability of and access to institutional resources from the perspectives of URM students in doctoral nursing programs at PWUs. It is hoped that the findings of this study may in turn help to elucidate the facilitators and barriers that contribute to admission, retention, attrition, and graduation of URM students in order to design better, targeted diversity initiatives in nursing education. In the long-term, the education of a more diverse pool of nurses may lead to a more diverse nursing workforce, which will benefit an ever-increasing diverse society in which health disparities, inequities, and inequalities still exist.

The study design was constructivist grounded theory. Participants were recruited using social media, flyers, and snowball sampling. Recruitment yielded 20 participants, who self- identified as an URM, spoke English, and attended a public or private PWU with a PhD in nursing program. Semi-structured interviews were audio-taped and transcribed. Iterative, simultaneous data collection and analysis used the ATLAS ti data management software program. Findings indicate that multiple factors, positive and negative, influenced URM PhD nursing students’ experiences at PWUs. Four overarching themes emerged: preadmission history and preparedness, becoming a scholar, support and resources and the journey toward graduation and beyond. Subcategories included multiple support systems; racial, ethnic and cultural influences; decision-making processes; and academic environment and resources. Addressing these multifactorial factors may broaden academic nursing’s understanding of how to foster successful degree attainment with a significantly diverse professoriate and clinical workforce.

ABSTRACT

HEALTH AND ITS CONTEXTUAL DETERMINANTS OF RURAL ADOLESCENTS IN CALIFORNIA

Alexa Colgrove Curtis

Background: Adolescence is a critical developmental period, providing the foundation for both opportunity and risk in adult life. The sociocultural context of the rural community presents unique challenges for rural adolescent health. Patterns of connectedness between the adolescent and the social environment have demonstrated mitigation of risk behaviors in previous studies.

Purpose: To describe the health of rural adolescents, 12 to 17 years, in California and to explore the relationship between health behaviors and connectedness to the social context among middle adolescents, ages 14 to 17 years, in the rural community.

Method: A secondary data analysis of the 2005 and 2003 Adolescent California Health Interview Survey (CHIS) was conducted in an ethnically and economically diverse sample of 663 and 492, respectively. The 2005 CHIS survey was used to examine the rural adolescent health in California. The 2003 CHIS survey was used to examine the influence of social connectedness on health behaviors.

Results: A majority of rural adolescents in California report good to excellent health however significant risk behaviors exist including impaired fitness and nutrition, sexual health risks, substance use, depression, and intra-personal violence. The most influential connectedness factor demonstrating reduced health risk is the home environment, in particular an adult within in the home who "believes the adolescent will be a success". Although the majority of rural adolescents can identify a usual source of care, few are certain they can access confidential services. Many adolescents, particularly minority and low income youth, rely upon community health services.

Conclusions: Adolescence is a critical developmental period and adolescents are a potentially vulnerable population. Health risks exist within the rural adolescent population at least equivalent to urban and suburban settings but rural adolescents may be particularly vulnerable related to limited resources to support positive development. Connnectedness to social contexts are important for the health of middle adolescents in the rural community. Further research is required examining health and health behaviors, and relationship to social connectedness in rural adolescents. Research that adequately samples high risk rural adolescents is particularly needed.

African American women (AAW) experience the trifecta of intersections: Black, female, and live with HIV infection at a disproportionately higher rate compared to other women. Yet, little is known about these intersections on the stigmatizing and quality of life (QOL) experiences of AAW living with HIV infection. The purposes of this secondary research were to describe HIVstigma and QOL, explore the association between HIVstigma and QOL, and determine the influence of social (age, education, income, and partner status) and health (CD4 count, comorbidities, and emergency department admission) contextual factors on HIVstigma and QOL in a sample of 169 AAW with HIV infection living in Cleveland, OH and the San Francisco Bay Area, CA. Results are discussed through the lens of intersectionality and Black feminism.

The sample was a middle-aged group of AA mothers who were low-income, not partnered, educated beyond high school, on public healthinsurance, unemployed, and lived in permanent housing.They reported a moderate level of HIV QOL and stigma. Partnered, college-educated women with less comorbidities reported better QOL, particularly for life satisfaction. Regardless of social background and health issues, women felt stigmatized by their community and healthcare professionals. HIV-QOL (disclosure of HIV, burden of HIV medications, and life satisfaction) was associated with HIV-stigma. Results of regression analyses of the social and health predictors of stigma and QOL indicate women with less comorbidities reported less personal and public stigma; and, college-educated women reported better overall QOL, better health, and less burden of taking HIV medications.

Conclusions are stigma can be a major obstacle for HIV/AIDS prevention and treatment; and,social support such as having a partner or being married, having a college education, and limiting comorbidities can have a positive effect on QOL and stigma.This study addressed a gap in science by considering social and health characteristics on stigma and QOL as perceived by AAW living with HIV infection. These findings may help in the development of HIV/AIDS health education interventions and policies that are holistic, gender-appropriate, culturally acceptable, and address the unique personal, social, and health concerns of and support needed by AAW.

Background: Cardiovascular disease (CVD) is the leading cause of death among all major racial and ethnic groups in the United States (US) and worldwide. Filipinos are the second largest Asian immigrant group in the US. Healthful lifestyle behaviors are cardioprotective factors, but have been under-, overestimated, or not studied among Asian American subgroups.

Objective: The purpose of this dissertation was to describe the cardiovascular health, cardiovascular mortality, cardiometabolic and lifestyle health behaviors, acculturation, and predictors associated with CVD in the Filipino American population.

Methods: A systematic review of the literature was conducted which focused on the cardiovascular mortality, disease and clinical and behavioral risks of Filipinos in the US. Two secondary analyses of the 2011-2012 California Health Interview Survey dataset were conducted which focused on the cardiovascular health, CVD, acculturation, metabolic and lifestyle health behavior of Filipino Americans (n = 555).

Results: The systematic review suggested that Filipino Americans are at high risk for developing cardiovascular disease, for having CVD-related clinical health risks, for engaging in unhealthy CVD lifestyle behaviors, and dying from CVD, as compared to White, non-Hispanic and other Asian Americans in general and by gender. The prevalence of CVD was 7.4% among Filipinos in California. Hypertension, diabetes, physical inactivity, being overweight/obese, and inadequate consumption of fruits and vegetables were prevalent among Filipinos. Multivariate logistic regression analysis indicated that only hypertension was a significant predictor of CVD, controlling for the effects of age, gender, being born in the US, and diabetes. When taking into consideration acculturation factors in chronic diseases and health behaviors, US-born Filipinos had a significantly lower proportion of chronic diseases as compared to Filipinos not born in the US. Filipinos who lacked English proficiency reported more hypertension as compared to Filipinos who reported proficiency in English. A higher proportion of several positive health behaviors were reported among Filipinos not born in the US and those who did not speak English at home ate the recommended 35 or more servings per week of fruits and vegetables compared to their counterparts.

Conclusions: Further research is needed for culturally-appropriate interventions, education, and prevention programs which focus on health behaviors and chronic diseases, such as CVD, for Filipino Americans.

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