Social Determinants of Health and Multimorbidity Among Adults 50 Years and Older in the United States

Background Living with two or more chronic conditions simultaneously—known as multimorbidity—has become increasingly prevalent as the aging population continues to grow. However, the factors that influence the development of multimorbidity are still not fully understood. Objectives The purpose of this study was to investigate the prevalence of multimorbidity among U.S. adults 50 years and older and identify associated factors with multimorbidity. Methods We used data from four cycles from the National Health and Nutrition Examination Survey (2011–2018) to examine the associations between social determinants of health and multimorbidity among American adults aged 50 years and older. A set of variables on socioeconomic status and health behaviors was chosen based on the social determinants of health conceptual framework developed by the World Health Organization. In our study, 4,552 participants were included. All analyses were accounted for a complex survey design and the use of survey weights. Multiple logistic regression analyses were performed to examine the associated factors with multimorbidity. Results The average age was 63.1 years, and 52.9% were female. The average number of chronic conditions was 2.27. The prevalence of multimorbidity was 63.8%, with high cholesterol and hypertension being the most prevalent conditions. In the adjusted model, age, gender, household income, citizenship status, health insurance, healthcare access, body mass index, and smoking status were found to be associated with living with multimorbidity. Discussion Our results indicate that continued efforts aimed at promoting smoking cessation and maintaining a healthy weight will be beneficial in preventing the onset of chronic conditions. Additional research is warranted to gain a deeper understanding of the interrelationships between gender, race/ethnicity, household income, citizenship status, health insurance, and healthcare access as social determinants of health in the context of multimorbidity. Further research will help us develop targeted interventions and policies to address disparities and improve health outcomes for individuals with multimorbidity.

Chronic Pain and Pain Management in Older Adults: Protocol and Pilot Results

Background Chronic pain occurs in 30% of older adults. This prevalence rate is expected to increase, given the growth in the older adult population and the associated growth of chronic conditions contributing to pain. No population-based studies have provided detailed, longitudinal information on the experience of chronic pain in older adults; the pharmacological and nonpharmacological strategies that older adults use to manage their chronic pain; and the effect of chronic pain on patient-reported outcomes. Objectives This article aims to describe the protocol for a population-based, longitudinal study focused on understanding the experience of chronic pain in older adults. The objectives are to determine the prevalence and characteristics of chronic pain; identify the pharmacological and nonpharmacological pain treatments used; evaluate for longitudinal differences in biopsychosocial factors; and examine how pain types and pain trajectories affect important patient-reported outcomes. Also included are the results of a pilot study. Methods A population-based sample of approximately 1,888 older adults will be recruited from the National Opinion Research Center at the University of Chicago’s AmeriSpeak Panel to complete surveys at three waves: enrollment (Wave 1), 6 months (Wave 2), and 12 months (Wave 3). To determine the feasibility, a pilot test of the enrollment survey was conducted among 123 older adults. Results In the pilot study, older adults with chronic pain reported a range of pain conditions, with osteoarthritis being the most common. Participants reported an array of pharmacological and nonpharmacological pain strategies. Compared to participants without chronic pain, those with chronic pain reported lower physical and cognitive function and poorer quality of life. Data collection for the primary, longitudinal study is ongoing. Discussion This project will be the first longitudinal population-based study to examine the experience and overall effect of chronic pain in older adults. Pilot study results provide evidence of the feasibility of study methods. Ultimately, this work will inform the development of tailored interventions for older patients targeted to decrease pain and improve function and quality of life.

Women Veterans’ Barriers to Care-Seeking for Cardiovascular Disease Prevention

Background Women veterans have a high prevalence of traditional and nontraditional risks for cardiovascular disease (CVD) including obesity and posttraumatic stress disorder. Experts from the U.S. Department of Veterans Affairs have called for actions to improve the cardiovascular health of this population. One approach is to assess women veterans’ barriers to care-seeking for CVD prevention, to inform future intervention research. Objective The objective of this study was to describe women veterans’ barriers to care-seeking for CVD prevention, guided by the theory of care-seeking behavior and concept awareness. Methods Using a cross-sectional, descriptive design, a national sample of 245 women veterans participated in an online survey about barriers to care-seeking. Participants provided narrative responses to open-ended items, endorsements to closed-ended items, and rankings of their top five barriers. Researchers conducted poststratification weighting of numerical data to reflect the women veteran population. Results Narrative responses described unaffordable and inaccessible services, feeling harassed or not respected in healthcare settings, and lack of awareness of risks for CVD. Frequently endorsed barriers were unaffordable and inaccessible services. Frequently ranked barriers were feeling not respected in healthcare settings and clinicians not recommending CVD prevention. Discussion Findings support concepts in theory of care-seeking behavior and concept awareness. Understanding women veterans’ barriers to care-seeking for CVD prevention can inform clinicians and researchers as they address these barriers.

The Effects of Race, Ethnicity, and Maternal Education on Infant Mortality

Background The state of New Jersey has a large Black/African American (AA) versus White racial disparity in infant mortality and educational level at childbirth. This disparity, measured by rate ratio, increases with greater maternal education among varied racial–ethnic groups. The nature of this disparity measured by rate differences has not been explored. Objectives Infant birth and mortality data were used to examine whether racial or ethnic disparities in infant mortality increased with greater maternal education, comparing rate differences and rate ratios. Racial and ethnic variations in the association between maternal education and infant mortality were examined. Methods Data were from the New Jersey State Health Assessment Data for all New Jersey births between 2014 and 2018 stratified by race and ethnicity, maternal education, and infant mortality (n = 481,333). R software was used to create a data set and estimate additive and multiplicative interactions, rate differences, and rate ratios for infant mortality by maternal race/ethnicity and educational levels among four racial–ethnic groups. Results Infant mortality was significantly greater for Black/AA and Hispanic mothers than for White mothers. At all educational levels, Black/AA mothers had the highest prevalence of infant mortality compared to other racial or ethnic groups. Rate differences in infant mortality showed a decrease in Black/AA–White differences for mothers with a high school education or less compared to mothers with a college degree. However, rate ratios showed an increase in Black/AA–White ratio with increasing education levels for mothers with high school education or less than mothers with a college degree. Risk ratios comparing infant mortality for Black/AA versus Hispanic or Asian mothers showed more than a twofold greater risk at all education levels for Black/AA infants. Finally, college-educated Black/AA mothers had significantly higher rates of infant mortality than White or Hispanic mothers with a high school education or less. Discussion/Implications Black/AA mothers with a college degree had a higher infant mortality rate than White, Hispanic, or Asian mothers with a high school education or less. Future research should address contextual/systemic contributors to this disparity.

Effect of the Nurse Work Environment on Older Hispanic Surgical Patient Readmissions

Background Readmissions following hospitalization for common surgical procedures are prevalent among older adults and are disproportionally experienced by Hispanic patients. One potential explanation for these disparities is that Hispanic patients may receive care in hospitals with lower-quality nursing care. Objectives The objective of this study was to evaluate the relationship between the hospital-level work environment of nurses and hospital readmissions among older Hispanic patients. Methods Using linked data sources from 2014 to 2016, we conducted a cross-sectional analysis of 522 hospitals and 732,035 general, orthopedic, and vascular surgical patients (80,978 Hispanic patients and 651,057 non-Hispanic White patients) in four states. Multivariable logistic regression models were employed to determine the relationship between the work environment and older Hispanic patient readmissions at multiple time periods (7, 30, and 90 days). Results In final adjusted models that included an interaction between work environment and ethnicity, an increase in the quality of the work environment resulted in a decrease in the odds of readmission that was greater for older Hispanic surgical patients at all time periods. Specifically, an increase in three of the five work environment subscales (Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, and Staffing and Resource Adequacy) was associated with a reduction in the odds of readmission that was greater for Hispanic patients than their non-Hispanic White counterparts. Discussion System-level investments in the work environment may reduce Hispanic patient readmission disparities. This study’s findings may be used to inform the development of targeted interventions to prevent hospital readmissions for Hispanic patients.

Experiences and Perceptions of E-Cigarette Cessation for Young Adults in Rural Communities

Background Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are the most commonly used tobacco products among young adults in the United States. Young adults in rural areas have a higher prevalence of ENDS use compared to their urban counterparts, yet there is limited evidence regarding the in-depth understanding of experiences and perspectives directly from young adults. Objectives The aim of this study was to explore individual experiences and perspectives about use and cessation of ENDS from young adults in rural areas. Methods This was a qualitative study using interpretive description for analysis. Young adults (18–24 years) who used ENDS every day but not other tobacco products (cigarettes, smokeless, etc.) in the past month and had an address in a rural county of Wisconsin were eligible; there were nine participants interviewed using Zoom. Interview questions focused on initial use, maintenance of use, experiences of quitting, and social and rural environmental contexts regarding ENDS. Results Three themes emerged with eight categories: (a) addiction to ENDS and health, (b) cessation and resources, and (c) rural environment and culture in ENDS addiction. Discussion Findings have implications for ENDS cessation interventions targeting young adults in rural areas.

Feasibility, Acceptability, and Preliminary Effectiveness of a Sleep Intervention in Adults at Risk for Metabolic Syndrome With Short Sleep Duration

Background The prevalence of short sleep duration is rising and is linked to chronic comorbidities, such as metabolic syndrome (MetS). Sleep extension interventions in adults with MetS comorbidities and short sleep duration are limited and vary widely in terms of approach and duration. Objectives This pilot study aimed to test the feasibility and acceptability of a personalized 12-week systematic sleep time extension intervention on post-intervention sleep outcomes in middle-aged adults at risk for MetS with actigraphy-estimated short sleep duration. Methods A single-arm, 12-week, 12-session systematic sleep time extension intervention was delivered weekly via videoconferencing. Feasibility and acceptability were assessed using retention rates and mean sleep diary completions. Sleep was estimated for 14 consecutive days prior to and immediately following the 12-week intervention using wrist actigraphy. Daytime sleepiness was assessed using the Epworth Sleepiness Scale. Paired sample t-tests modeled changes in study outcomes. Results Study participants (N = 41) had a mean age of 52 years and were mostly female and White; 86% attended >80% of sessions, and mean sleep diary completion was 6.7 diaries/week. Significant improvements in sleep from pre- to post-intervention included increased total sleep time, earlier sleep onsets, more regular sleep onsets, a higher sleep regularity index, and reduced daytime sleepiness. Extending sleep, as well as improving sleep timing and regularity in middle-aged adults with actigraphy-estimated short sleep duration and at risk for MetS, is feasible and acceptable. Discussion Behavioral sleep characteristics may be modifiable and present a novel behavioral paradigm for mitigating MetS risk. This pilot study provides a proof of concept for the feasibility, acceptability, and preliminary effectiveness of a systematic sleep time extension for middle-aged adults at risk for MetS with actigraphy-estimated short sleep duration.

An Integrative Review of Response Rates in Nursing Research Utilizing Online Surveys

Background Online surveys in nursing research have both advantages and disadvantages. Reaching a sample and attaining an appropriate response rate is an ongoing challenge and necessitates careful consideration when designing a nursing research study using an online survey approach. Objective In this study, we aimed to explore response rates and survey characteristics of studies by nurse researchers that used online methodologies to survey nurses, nursing students, and nursing faculty. Methods We conducted an integrative review of research studies that used online surveys for data collection published from 2011 to 2021. We examined response rates and survey characteristics such as recruitment method, use of incentives, question type, length of survey, time to complete the survey, and use of reminders. Results Our review included 51 studies published by nurses with target samples of nurses, nursing students, or nursing faculty. Study sample sizes ranged from 48 to 29,283, the number of respondents ranged from 29 to 3,607, and the response rates ranged from 3.4% to 98%, with an average of 42.46%. Few patterns emerged regarding recruitment or other factors to enhance response rates; only five studies used incentives. Conclusion Response rates to online surveys are unlikely to reach the rates seen in older mailed surveys. Researchers need to design online survey studies to be easily accessible, concise, and appealing to participants.

Symptoms in Patients Receiving Noninvasive Ventilation in the Intensive Care Unit

Background Although a multitude of studies have demonstrated the effectiveness of noninvasive ventilation (NIV) for treatment of respiratory insufficiency, there have been few investigations of patients’ experiences while receiving this common treatment. Identification of the presence, intensity, and distress of symptoms during NIV will inform the development and testing of interventions to best manage them and improve patients’ intensive care unit (ICU) experiences. Objective The objectives of this study were (a) to identify the presence, intensity, and distress of symptoms in patients receiving NIV in the ICU using a modified version of the Edmonton Symptom Assessment Scale (MESAS) and (b) to describe the most common and distressing symptoms experienced by patients. Methods A cross-sectional descriptive design was used with a convenience sample of 114 participants enrolled from three ICUs at one Midwestern medical center. Participants were approached if they were English-speaking, were 18 years old or older, and had an active order for NIV; exclusions included use of personal NIV equipment, severe cognitive impairment, or problems communicating. Demographic and clinical data were obtained from the electronic health record. Presence, intensity, and distress of patient-reported symptoms were obtained once using a modified, 11-item version of the MESAS. Results The mean age of participants was 68 years old, and 54.4% were male. The primary type of NIV was bi-level positive airway pressure; a nasal/oral mask was most frequently used. The symptoms experienced by most of the participants were thirst, anxiety, tiredness, and restlessness; these symptoms were rated as moderate or severe in both intensity and distress by most participants experiencing the symptoms. Discussion Patients in the ICU experience both intense and distressful symptoms that can be severe while undergoing treatment with NIV. Future research is warranted to determine these symptoms’ interrelatedness and develop interventions to effectively manage patient-reported symptoms.

Development and Psychometric Evaluation of the Children's Illness-Related Concerns Scale

Background Despite the effect of maternal breast cancer on many children, there is no valid or reliable quantitative measure of the concern that children attribute to their mothers' disease, which constrains both science and clinical practice. Objectives This study aimed to develop and psychometrically evaluate the initial measures of child-reported, illness-related concerns associated with maternal cancer. Methods The study was conducted in three phases: scoping review, item extraction from a battery of items obtained from school-aged children about general issues related to their mothers' breast cancer, and testing of the three proposed structural models of these extracted items using confirmatory factor analysis. The scoping review yielded five categories of illness-related concerns: altered family routines, uncertainty, concerns about illness contagion, maternal death, and maternal well-being. To reflect these five categories, 18 items were extracted from a 93-item questionnaire completed by 202 school-aged children regarding their mothers' breast cancer. Next, three structural models were hypothesized to assess the construct validity of illness-related concerns: five-, three-, and one-factor models. Confirmatory factor analysis was used to test and compare the models. Results The five-factor model best fit the data, and each factor showed adequate internal consistency reliability. These findings align with the a priori five-factor model informed by the scoping review. Conclusion The results provide initial evidence of the construct validity of the 18-item Children's Illness-Related Concerns Scale, which can be used to assess children's concerns and inform future intervention studies.

Interindividual Variability in Self-Monitoring of Blood Pressure Using Consumer-Purchased Wireless Devices

Background Engagement with self-monitoring of blood pressure (BP) declines, on average, over time but may vary substantially by individual. Objectives We aimed to describe different 1-year patterns (groups) of self-monitoring of BP behaviors, identify predictors of those groups, and examine the association of self-monitoring of BP groups with BP levels over time. Methods We analyzed device-recorded BP measurements collected by the Health eHeart Study—an ongoing prospective eCohort study—from participants with a wireless consumer-purchased device that transmitted date- and time-stamped BP data to the study through a full 12 months of observation starting from the first day they used the device. Participants received no instruction on device use. We applied clustering analysis to identify 1-year self-monitoring, of BP patterns. Results Participants had a mean age of 52 years and were male and White. Using clustering algorithms, we found that a model with three groups fit the data well: persistent daily use (9.1% of participants), persistent weekly use (21.2%), and sporadic use only (69.7%). Persistent daily use was more common among older participants who had higher Week 1 self-monitoring of BP frequency and was associated with lower BP levels than the persistent weekly use or sporadic use groups throughout the year. Conclusion We identified three distinct self-monitoring of BP groups, with nearly 10% sustaining a daily use pattern associated with lower BP levels.

Tailored Nurse Support Program Promoting Positive Parenting and Family Preservation

Background Public health nurse home visiting is a promising approach for addressing the complex needs of families at risk of child maltreatment. The Colorado Nurse Support Program advances service provision by using evidence-based practices to provide tailored assessment and intervention to low-income, primiparous, and multiparous families with children under 18 years of age identified as high risk by county human service systems. Objectives This study aimed to test the effects of the Nurse Support Program on child protective services case characteristics between Nurse Support Program families and a demographically comparable reference group of families and evaluate changes in parenting outcomes from pre- to postprogram involvement for Nurse Support Program families. Methods We used a matched comparison group quasi-experimental design in which families in the Nurse Support Program (n = 48) were compared to families (n = 150) who were identified using administrative data from Colorado’s Comprehensive Child Welfare Information System. Outcomes were child protective case characteristics (child protection referrals, open assessments, founded assessments, open cases, and children’s placement in out-of-home care) and parenting outcomes. Results Nurse Support Program families were less likely to have a child protection case opened or have their child placed in out-of-home care. There were no significant between-group differences in child protection referrals, open assessments, or founded assessments. Families in the Nurse Support Program showed improvements in parenting outcomes over time. Discussion Findings suggest that the Nurse Support Program is a successful public health nurse home-visiting approach to promote positive parenting and family preservation among families with complex needs. Implementing tailored public health nurse home-visiting programs, such as the Nurse Support Program, should continue to be evaluated and supported to mitigate the public health risk of child maltreatment.

An Evaluation of the Multifactorial Model of Cancer-Related Cognitive Impairment

Background Up to 45% of patients report cancer-related cognitive impairment (CRCI). A variety of characteristics are associated with the occurrence and/or severity of CRCI. However, an important gap in knowledge of risk factors for CRCI is the relative contribution of each factor. The multifactorial model of cancer-related cognitive impairment (MMCRCI) is a conceptual model of CRCI that can be used to evaluate the strength of relationships between various factors and CRCI. Objectives The purpose of this study was to use structural regression methods to evaluate the MMCRCI using data from a large sample of outpatients receiving chemotherapy (n = 1,343). Specifically, the relationships between self-reported CRCI and four MMCRCI concepts (i.e., social determinants of health, patient-specific factors, treatment factors, and co-occurring symptoms) were examined. The goals were to determine how well the four concepts predicted CRCI and determine the relative contribution of each concept to deficits in perceived cognitive function. Methods This study is part of a larger, longitudinal study that evaluated the symptom experience of oncology outpatients receiving chemotherapy. Adult patients were diagnosed with breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding 4 weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent. Self-reported CRCI was assessed using the attentional function index. Available study data were used to define the latent variables. Results On average, patients were 57 years of age, college educated, and with a mean Karnofsky Performance Status score of 80. Of the four concepts evaluated, whereas co-occurring symptoms explained the largest amount of variance in CRCI, treatment factors explained the smallest amount of variance. A simultaneous structural regression model that estimated the joint effect of the four exogenous latent variables on the CRCI latent variable was not significant. Discussion These findings suggest that testing individual components of the MMCRCI may provide useful information on the relationships among various risk factors, as well as refinements of the model. In terms of risk factors for CRCI, co-occurring symptoms may be more significant than treatment factors, patient-specific factors, and/or social determinants of health in patients receiving chemotherapy.

Distinct Profiles of Morning and Evening Fatigue Co-Occurrence in Patients During Chemotherapy

Background Morning and evening fatigue are distinct and distressing symptoms experienced during chemotherapy that demonstrate a large amount of interindividual variability. Objectives The objectives of this study were to identify subgroups of patients with distinct morning and evening fatigue co-occurrence profiles and evaluate for differences among these subgroups in demographic, clinical, and symptom characteristics and quality of life. Methods Oncology patients (n = 1,334) completed the Lee Fatigue Scale to self-report morning and evening fatigue, six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct morning and evening physical fatigue profiles. Results Four distinct morning and evening fatigue profiles were identified (i.e., Both Low, Low Morning + Moderate Evening, Both Moderate, and Both High). Compared to the Both Low profile, the Both High profile was significantly younger, less likely to be married or partnered, more likely to live alone, had a higher comorbidity burden, and lower functional status. The Both High profile had higher levels of anxiety, depressive symptoms, sleep disturbance, and pain and lower levels of quality of life. Discussion The variability in the morning and evening severity scores among the four profiles supports the hypothesis that morning and evening fatigue are distinct but related symptoms. Clinically meaningful levels of both morning and evening fatigue were reported by 50.4% of our sample, which suggests that the co-occurrence of these two symptoms is relatively common. Patients in Both Moderate and Both High profiles experienced an extremely high symptom burden that warrants ongoing assessments and aggressive symptom management interventions.