Health-promoting Resources Research Articles

A qualitative study of long-term ICU patients' inner strength and willpower: Family and health professionals as a health-promoting resource.

To explore how the presence of family and health professionals influences long-term critically ill patients' inner strength and willpower as an incitement to keep fighting for recovery. This study reports long-term critically ill patients' experiences of family and health professionals as health-promoting resources in terms of significance for their inner strength and willpower. Earlier research on this topic is scarce. A qualitative, hermeneutic-phenomenological approach, within the context of Antonovsky's salutogenic theory. Seventeen long-term critically ill patients were interviewed once, at 6-18months after ICU discharge. The consolidated criteria for reporting qualitative research (COREQ) were used (Supplementary File 1). Four main themes identified how family and staff promoted and challenged the patient's inner strength and willpower: (a) the importance of family and friends; my family was surrounding me, (b) staff contributions, (c) challenges to inner strength and willpower in relation to family and (d) loneliness and indifferent care. This study brings new knowledge from the long-term critically ill patient's view about the impact of family, friends and nurses on the patient's inner strength and willpower. All impact is experienced positively and negatively. Knowledge from the long-term critically ill patient's view is vital in nurse-patient interactions to facilitate liberation of inner strength and willpower.

Abstract 16044: Association of Area Deprivation Index With Recurrent Cardiovascular Outcomes: Does Cardiac Rehabilitation Participation Mitigate Effects?

Introduction: Neighborhood location impacts access to health-promoting resources and outcomes. Cardiac rehabilitation (CR) provides a multidisciplinary approach that improves cardiovascular outcomes. We evaluated the association of Area Deprivation Index (ADI) and cardiovascular events in individuals with incident Heart Failure (HF) or myocardial infarction (MI) and the modifying effect of CR. Methods: We identified an observational cohort admitted with primary diagnosis of 1) MI with percutaneous coronary intervention or 2) a primary diagnosis of incident HF from 2010-2018 at a multi-site regional center. We derived ADI from patient home address and then categorized into quartiles. Demographics, clinical covariates, and CR participation post-hospitalization were obtained from the electronic medical record. We compared rates of readmission for a cardiovascular primary diagnosis and mortality across ADI quartiles. Analyses were then stratified by CR participation. Results: In a cohort of 6957 (38.2% women, 88.7% white) with adjustment for covariates, increasing ADI was significantly associated with higher rates of cardiovascular rehospitalization (p<0.01), Acute Coronary Syndrome (ACS) rehospitalization (p=0.01), HF rehospitalization (p<0.01), and all-cause mortality (p=0.04), Table. When we stratified across CR participation, those with participation had significantly lower rehospitalizations (p<0.01) and mortality (p<0.01) when compared to the no CR group. There was no significant effect of ADI on outcomes in the CR group. Discussion: We found increased ADI was adversely associated with mortality and rehospitalizations in cardiac patients. For those participating in CR, there was 1) no significant effect of ADI and 2) decreased incidence of adverse outcomes vs. those who did not participate in CR. Given the benefit of CR participation on ADI’s adverse effect on outcomes, future interventions should focus on increasing CR participation.

A geospatial analysis of Type 2 Diabetes Mellitus and the food environment in urban New Zealand

The aim of this research is to analyse the spatial epidemiology of Type 2 Diabetes Mellitus (T2DM) and investigate associations with the built environment in urban New Zealand. Data on T2DM was sourced from the New Zealand Virtual Diabetes Register (2016), and data on environmental variables sourced from the Ministry for Primary Industries and Territorial Authorities (2013–2016). Novel measures of the built environment using an enhanced two-step floating catchment area model were established using data on fast food outlets, takeaways, dairy/convenience stores, supermarkets and fruit/vegetable stores. Rates of T2DM per 1000 population and standardised morbidity ratios were computed and visualised for all urban areas. Getis Ord was used to assess spatial clustering, and Bayesian modelling was used to understand associations between T2DM and environmental variables. Results indicate that T2DM is influenced by demographic factors, spatially clustered and associated with accessibility to environmental exposures. Health-promoting resources, such as fruit/vegetable stores, were shown to have a consistently protective effect on T2DM while those considered detrimental to health showed varying, and largely insignificant, associations. This is the first study in New Zealand to spatially quantify the effects of multiple environmental exposures on population level T2DM for all urban areas using a geospatial approach. It has implications for both policy and future research efforts as a deeper knowledge of local environments forms a basis on which to better understand spatial associations between the built environment and health, as well as formulate policy directed toward environmental influences on chronic health conditions.

Neighborhood Poverty Histories and Physical Activity Among Children: Findings From the Geographic Research on Wellbeing (GROW) Study.

Examine the association between neighborhood poverty histories and physical activity, and the moderation effect of family poverty and the mediation effect of built environments in such association. A cross-sectional study of the Geographic Research on Wellbeing (2012-2013), a follow-up survey of statewide-representative Maternal and Infant Health Assessment (2003-2007). California. A total of 2493 women with children. Outcome measures are (1) daily leisure physical activity and (2) days of physical activity among children. An independent variable is poverty histories of census tract where the child resided. Mediators were mother-perceived social cohesion, mother-perceived neighborhood safety, distance to the closest park, and park acreage within 0.5 miles from the home. A moderator is family poverty. Weighted regression analysis. Family poverty was a significant moderator (P < .05); poor children in neighborhoods with long-term moderate poverty, long-term high poverty, or increasing poverty (vs long-term low poverty) had greater odds of daily physical activity (odds ratio [OR] = 1.46, 1.50, 1.66, respectively). Nonpoor children in neighborhoods with long-term moderate poverty or increasing poverty (vs long-term low poverty) were associated with decreased odds of daily physical activity (OR = 0.61 and 0.44, respectively). Mediation associations were insignificant (P > .05). The combined effect of family financial strains and neighborhood economic resources might prevent poor children in neighborhoods with long-term low poverty and decreasing poverty from utilizing health-promoting resources in neighborhoods.

Perspectives On Integrating Health Into The Low-Income Housing Tax Credit: A Qualitative Study.

While there is increasing attention to the ways in which safe and affordable housing may promote improved health, less work has focused on the role of the Low-Income Housing Tax Credit (LIHTC) program-the largest source of affordable housing in the United States. Through qualitative interviews, we examined the perspectives of diverse stakeholders in the housing sector on the opportunities and obstacles involved in including health-related criteria in LIHTC funding decisions. Our interviews revealed a growing desire within the housing sector to address health needs but, with the exception of green building criteria, a lack of clear standards on best practices. Stakeholders noted the challenges of effectively partnering with local health institutions, the need to develop sustainable payment mechanisms for health-related services, and the importance of locating developments near health-promoting resources. By describing mechanisms for integrating health services into the affordable housing infrastructure, this study helps lay the groundwork for the development of cross-sector partnerships.

Health-promoting factors in higher education for a sustainable working life \u2013 protocol for a multicenter longitudinal study

BackgroundThe World Health Organization has highlighted the importance of health promotion for health service providers in order to ensure sustainable working life for individuals involved in providing health services. Such sustainability begins when students are preparing to manage their own future health and welfare in working life. It has been suggested that universities, employees and trainee health professionals should adopt or follow a salutogenic approach that not only complements the providing of information on known health risks but also favors health promotion strategies. This paper describes the study design and data collection methods in a planned study aiming to explore health-promoting factors for a sustainable working life among students in higher education within healthcare and social work.MethodsThis protocol describes a multicenter longitudinal study involving Swedish students on higher education programs in the healthcare and social work sectors. In 2018, the study invited students on seven education programs at six universities to participate. These programs were for qualification as: biomedical laboratory scientists (n = 121); dental hygienists (n = 87); nurses (n = 1411); occupational therapists (n = 111); physiotherapists (n = 48); radiographers (n = 60); and, social workers (n = 443). In total, 2283 students were invited to participate. Participants completed a baseline, a self-reported questionnaire including six validated instruments measuring health-promoting factors and processes. There are to be five follow-up questionnaires. Three while the students are studying, one a year after graduating, and one three years after graduating. Each questionnaire captures different health-promoting dimensions, namely: health-promoting resources (i.e. sense of coherence); occupational balance; emotional intelligence; health and welfare; social interaction; and work and workplace experiences/perceptions.DiscussionThis study focuses on the vastly important aspect of promoting a sustainable working life for healthcare and social work employees. In contrast to previous studies in this area, the present study uses different, validated instruments in health promotion, taking a salutogenic approach. It is hoped that, by stimulating the implementation of new strategies, the study’s findings will lead to education programs that prepare students better for a sustainable working life in healthcare and social work.

The Washtenaw ID Project: A Government-Issued ID Coalition Working Toward Social, Economic, and Racial Justice and Health Equity.

Introduction. The policing of identities through policies that restrict access to IDs issued by U.S. governmental entities disparately affects communities of color; communities who identify as low-income, immigrant, older, and/or transgender; and community members who experience chronic mental illness, housing instability, or incarceration. Yet government-issued IDs are increasingly needed to access health-promoting resources such as housing, banking, social services, and health care, and in interactions with law enforcement. Methods. Since 2012, the Washtenaw ID Project's coalition-building process has involved communities affected by restrictive ID policies, advocates, and institutional stakeholders to enact community and systems change regarding inequities in government-issued IDs. We discuss the coalition-building process that culminated in the implementation of a photo ID issued by Washtenaw County government as a policy change strategy. We also highlight the community-academic research partnership evaluating the effectiveness of the Washtenaw ID in order to ensure equity in Washtenaw ID access and acceptance. Results. In 2015, 77% of Washtenaw ID holders reported having no other locally accepted ID. At follow-up, Washtenaw ID holders reported favorable Washtenaw ID acceptance rates in several domains (e.g., health care, school), but not when accessing banking services and housing. Additionally, community discussions suggested racial inequities in carding and ID acceptance. We discuss next steps for policy improvement to ensure equitable impact of the ID. Conclusions. Without national policy reform instating access to government-issued IDs for all, the social movement to establish local IDs may improve access to health-related resources contingent on having an ID. Careful attention must be paid to community organizing processes, policy implementation, and evaluation to ensure equity.

P12 Health Perceptions of Children in the Mississippi Delta

Background High rates of food insecurity, poverty, lack of educational attainment and limited health-promoting resources have contributed to a largely obesogenic environment in rural Mississippi. Health behavior, however, depends not only on the objective environment but also on how a person perceives that environment. Objective The purpose of this study was to identify adolescents’ perceptions of healthy eating and health in a small, rural town in the Mississippi Delta. Study Design, Settings, Participants Subjects were a convenience sample of 14 adolescents, between ages 10 and 18, who were recruited to participate at a local food pantry. Measurable Outcome/Analysis Qualitative interviews included questions concerning knowledge, perceptions, and definitions of physical activity and healthy eating, as well as available resources for obtaining health-related information. A thematic approach was used to analyze interview transcripts. Results Participants displayed an overall lack of knowledge of and saw little value in healthy eating and physical activity. Informational resources were identified as gym and health class in school, parents, sports coaches, television and the grocery store; although, gym and health class were mentioned predominately for promoting physical activity, not healthy eating. Because of the lack of maintained sidewalks or a fitness center, physical activity outside of the gym class only takes place during sports-related events. Adolescents identified their parent's cooking as both a facilitator and barrier to eating healthy. Conclusion Utilizing school gym class as a platform to teach nutrition education for adolescents would provide knowledge and awareness in a setting that participants deem informative. Also, a parent-child cooking class teaching practical skills and cooking techniques in an after-school setting can improve cooking at home, which is currently labeled a barrier. This study provided important insight for future research studies by describing barriers to healthy behaviors for adolescents in this rural community, as well as identifying existing and needed resources. Funding University of Mississippi.

Embedding research recruitment in a community resource e-prescribing system: lessons from an implementation study on Chicago's South Side.

The study sought to implement and assess the CommunityRx e-prescribing system to recruit research participants from a predominantly non-Hispanic Black community on Chicago's South Side. CommunityRx integrates with electronic medical record systems to generate a personalized list of health-promoting community resources (HealtheRx). Between December 2015 and December 2016, HealtheRxs distributed at outpatient visits to adults with asthma or chronic obstructive pulmonary disease also incentivized participation in a pulmonary research registry. Usual practices for registry recruitment continued in parallel. Focus groups established acceptability and appropriateness among the target population. Pulmonary research registry recruitment information was included on 13437 HealtheRxs. Forty-one (90% non-Hispanic Black) patients responded with willingness to participate and 9 (8 non-Hispanic Black) returned a signed consent required to enroll. Usual recruitment practices enrolled 4 registrants (1 non-Hispanic Black). Automating research recruitment using a community e-prescribing system is feasible. Implementation of an electronic medical record-integrated, community resource referral tool promotes enrollment of eligible underrepresented research participants; however, enrollment was low.

Prevalence of type 2 diabetes mellitus among hepatitis C virus-infected patients: a protocol for systematic review and meta-analysis

IntroductionThe ever-increasing global hepatitis C infection is fueling the burden of diabetes mellitus, which exaggerates various complications and may be a cause of death for millions. Several studies have reported that hepatitis C virus infection is an important risk factor for the development of diabetes mellitus. However, the results of fragmented studies reported variable and inconsistent findings on the prevalence of type 2 diabetes mellitus among hepatitis C virus-infected patients. Therefore, this protocol for meta-analysis will determine the overall pooled prevalence of type 2 diabetes mellitus in patients infected with hepatitis C virus.Methods and analysisThis systematic review and meta-analysis will include original articles of cohort and cross-sectional studies published in English. A systematic search will be performed in PubMed, Science Direct, Scopus, and Google Scholar. A fixed/random-effects meta-analysis model will be used to estimate the global pooled prevalence of type 2 diabetes mellitus among hepatitis C virus-infected patients. Sensitivity analysis will be conducted to check the stability of the summary estimate. Heterogeneity will be assessed using the I2 statistic. Subgroup analysis will also be conducted based on geographical region. Funnel plots and Egger’s test and Begg’s test will be used to assess for publication bias.Ethics and disseminationThe review is based on published data; therefore, ethical approval is not required. The systematic review and meta-analysis will summarize the existing data on the prevalence of type 2 diabetes mellitus among hepatitis C virus-infected patients at the global level. This provides the empirical evidence necessary for researchers, policymakers, and public health stakeholders to derive health-promoting policies, allocate resources, and set priorities for monitoring future trends. The final result will be presented at annual scientific meetings, conferences, and seminars. Moreover, it will also be published in a peer-reviewed reputable journal. We also plan to review every 5 years to provide updated information.Systematic review registrationPROSPERO CRD42018083409

Social contributors to cardiometabolic diseases in indigenous populations: an international Delphi study

ObjectiveThe objective of this study was to identify priority social factors contributing to indigenous cardiometabolic diseases. Study designA three-round Delphi process was used to consolidate and compare the opinions of 60 experts in indigenous cardiometabolic health from Australia, New Zealand and the United States. MethodsRound one: three open-ended questions: (i) historical, (ii) economic and (iii) sociocultural factor contributors to cardiometabolic disease risk. Round two: a structured questionnaire based on the results from the first round; items were ranked according to perceived importance. Final round: the items were reranked after receiving the summary feedback. ResultsSeveral key findings were identified: (i) an important historical factor is marginalisation and disempowerment; (ii) in terms of economic and sociocultural factors, the panellists came to the consensus that the socio-economic status and educational inequalities are important; and (iii) while consensus was not reached, economic and educational factors were also perceived to be historically influential. ConclusionThese findings support the need for multilevel health promotion policy. For example, tackling financial barriers that limit the access to health-promoting resources, combined with improving literacy skills to permit understanding of health education.

It Works, But For Whom? Examining Racial Bias in Carding Experiences and Acceptance of a County Identification Card

Purpose: Policies that restrict access to U.S. government-issued photo identification (ID) cards adversely affect multiple marginalized communities. This context impedes access to health-promoting resources that increasingly require government-issued IDs and exacerbates health inequities. In 2015, Washtenaw County, Michigan, implemented the Washtenaw ID to improve access to resources contingent upon having an ID. We employed an audit study to examine whether Washtenaw ID users experienced racially biased treatment in carding experiences and acceptance of the Washtenaw ID.Methods: Seven 25- to 32-year-old mystery shoppers (two Latina, three black, and two white women) attempted to purchase a standardized basket of goods, including an age-restricted item in Washtenaw County stores (n=130 shopping experiences). We examined whether experiences of being asked for ID and acceptance of the Washtenaw ID varied by race/ethnicity.Results: Each shopper visited 9–22 stores. Shoppers were asked for ID in 63.1% of shopping experiences. Of these, the Washtenaw ID was accepted 91.5% of the time. Among those who were asked for ID, a higher percentage of Latina (16.0%) shoppers had their Washtenaw IDs rejected than black (6.3%) and white (4.0%) shoppers, although differences were not statistically significant (p=0.27). Latina shoppers had 2.9 times the odds of receiving a comment about their Washtenaw ID relative to white shoppers (OR=2.92, p=0.08), comments that were nonpositive.Conclusion: Local IDs may improve access to resources contingent upon having an ID. However, racialization processes, including anti-immigrant sentiments, may inhibit the mitigating goal of local IDs. Continued attention to the health equity impacts of equity-driven interventions is warranted.

Examining protective and buffering associations between sociocultural factors and adverse childhood experiences among American Indian adults with type 2 diabetes: a quantitative, community-based participatory research approach

ObjectivesThe purpose of this study was to determine the frequency of select adverse childhood experiences (ACEs) among a sample of American Indian (AI) adults living with type 2 diabetes (T2D)...

“They Are Clipping Our Wings”: Health Implications of Restrictive Immigrant Policies for Mexican-Origin Women in a Northern Border Community

We examine racialization processes experienced by women of Mexican origin in a northern border community during a protracted period of restrictive immigrant policies that have disparately affected Mexican-origin communities, and consider pathways through which these experiences may affect health. This grounded theory analysis draws on interviews conducted in 2013–2014 with 48 first, 1.5, and second generation Mexican-origin women living in Detroit, MI. Racialization processes blurred boundaries between Latinas/os, immigrants, and undocumented immigrants. Racialized policies and interactions required women to negotiate shifting and often precarious social and political terrain. We describe racializing markers used by agents of multiple institutions to assess the legal status of women and members of their social networks, shaping their access to the resources over which institutional agents held power. Specifically, we consider the dynamic mechanisms by which multiple legal, social, and employment institutions exacted immigrant policing and bureaucratic surveillance. These include: (1) interior and border immigration enforcement agents’ active surveillance of residents; (2) local law enforcement officials’ assertion of authority over driver’s licenses and contact with immigration officials, often in traffic-related encounters; (3) Secretary of State clerks’ discretion in assessing legal status and issuing driver’s licenses and state IDs; (4) social welfare agents’ scrutiny of citizenship status in determining access to nutritional, economic, and medical resources; and (5) employers’ exploitation of these structural vulnerabilities to justify unfair treatment of immigrant workers. We theorize several mechanisms, by which these processes affect health, including: stigmatization; hypervigilance; and restricted access to health-promoting resources.

Health-related regional and neighborhood correlates of sexual minority concentration: A systematic review.

BackgroundA growing literature explores spatial patterns of regional and neighborhood correlates of sexual minority (e.g., lesbian, gay, bisexual) concentration. Such patterns have implications for health and wellbeing if there are differences in health-promoting or health-hindering resources in neighborhoods or regions. We conducted a systematic review to assess sexual minority concentration in relation to area unit characteristics.MethodsWe included only records published after 1973 and made no exclusions by geography or language. We searched 11 databases (Academic Search Complete, CINAHL, Embase, GeoBase, GeoRef, LGBT Life, PsycINFO, PubMed/MEDLINE, Scopus, Sociological s, Web of Science) on November 19–21, 2016. We searched reference lists of included records. We used the following inclusion criteria: (1) Record is a quantitative study (that is, it uses statistics to describe or associate two or more variables); (2) Record is about (a) migration or internal migration of, (b) area unit selection by, or (c) concentration of sexual minority people (defined by identity, behavior, or attraction); (3) Criterion 2 is linked to the characteristics of regions or neighborhoods (at any spatial scale).ResultsDual independent coding resulted in 51 records meeting inclusion criteria from the original pool of 5,591. From these records, we identified the 647 reported results linking sexual minority concentration with area unit characteristics. Of these, 132 were unadjusted relationships between sexual minority concentration and four theory-informed domains of neighborhood influence on health. We identified greater concentration of sexual minorities in regions with more resources and in more urban regions. A limited but troubling literature at the neighborhood level suggested potentially higher concentrations of sexual minorities in neighborhoods with fewer resources.ConclusionsThere are substantial gaps in the literature. We discuss the implications of our findings and gaps in relation to key theories of sexual minority health.RegistrationThe review was not registered with PROSPERO because it was not eligible for registration at the time of the research project’s initiation due to the outcome of interest.

Avenues of Influence: the Relationship between Health Impact Assessment and Determinants of Health and Health Equity.

This study aims to identify perceived impacts of Health Impact Assessment (HIA) on decision-making, determinants of health, and determinants of health equity and outline the mechanisms through which these impacts can occur. The research team conducted a mixed-methods study of HIAs in the USA. First, investigators collected data regarding perceived HIA impacts through an online questionnaire, which was completed by 149 stakeholders representing 126 unique HIAs. To explore in greater depth the themes that arose from the online survey, investigators conducted semi-structured interviews with 46 stakeholders involved with 27 HIAs related to the built environment. This preliminary study suggests that HIAs can strengthen relationships and build trust between community and government institutions. In addition, this study suggests that HIA recommendations can inform policy and decision-making systems that determine the distribution of health-promoting resources and health risks. HIA outcomes may in turn lead to more equitable access to health resources and reduce exposure to environmental harms among at-risk populations. Future research should further explore associations between HIAs and changes in determinants of health and health equity by corroborating findings with other data sources and documenting potential impacts and outcomes of HIAs in other sectors.

Longitudinal Associations of Neighborhood-level Racial Residential Segregation with Obesity Among Blacks.

Despite 50 years since the passage of the Fair Housing Act of 1968, the majority of black Americans continue to live in highly segregated communities. Differing exposure to obesogenic environments in segregated neighborhoods may contribute to racial disparities in obesity prevalence. We used prospective data from the Coronary Artery Risk Development in Young Adults (CARDIA) study to examine associations between levels of neighborhood-level racial residential segregation and incident obesity in black men and women. Obesity, determined by measured anthropometry, and residential segregation, measured using the local Gi*statistic, were recorded at baseline and follow-up at years 7, 10, 15, 20, and 25. We used marginal structural survival models to account for time-dependent confounding and for loss to follow-up. Black women living in highly segregated neighborhoods at the prior exam were 30% more likely to become obese during the follow-up period as compared with women living in neighborhoods with low levels of segregation after adjustment for sociodemographic and cardiovascular risk covariates (hazard ratio = 1.3 [95% confidence interval = 1.0, 1.7]). Cumulatively high exposure to segregation averaged across time points was associated with 50% higher hazard of obesity (hazard ratio = 1.5 [95% confidence interval = 1.0, 2.3]) among women. We observed few differences in obesity incidence among men by segregation levels. Fewer health-promoting resources, stressful neighborhood context, and social norms that are less stigmatizing of obesity may contribute to these findings, but more research on specific pathways leading from segregation to obesity is needed to understand differing patterns between men and women.

Neighborhood Concentrated Disadvantage and Adult Mortality: Insights for Racial and Ethnic Differences

While racial and ethnic differences in mortality are pervasive and well documented, less is known about how mortality risk varies by neighborhood socioeconomic status across racial and ethnic identity. We conducted a prospective analysis on a sample of adults living at or below 300% poverty with 8 years of the National Health Interview Survey (N = 159,400) linked to 11,600 deaths to examine the association between neighborhood disadvantage and mortality for non-Hispanic whites, non-Hispanic blacks, and U.S.- and foreign-born Hispanics. Using multilevel logistic regression, we find that the probability of death from any cause for lower-income adults is higher in more-disadvantaged neighborhoods, compared to less-disadvantaged neighborhoods, but only for whites. The adjusted likelihood of death for blacks and foreign-born Hispanics is not associated with neighborhood disadvantage, and the likelihood of death for U.S.-born Hispanics is lower in more-disadvantaged neighborhoods. While future research and policy should focus on improving health-promoting resources in all communities, care should be given to better understanding why race/ethnic groups have differential mortality returns with respect to area-specific socioeconomic conditions.

A spatial analysis of race, local health-promoting resources and preventable hospitalizations

IntroductionPreventable hospitalizations (PHs) for chronic conditions could have been avoided if treated with primary healthcare. PH rates are higher among African Americans, and in areas with less healthcare. Little is known about the effects of non-healthcare local health-promoting resources (LHPRs). The objective of this study is to determine associations between LHPRs and chronic PH rates in Maryland, and to assess spatial clustering of areas with high PH rates. MethodsHospitalizations in 2010 were obtained from the Maryland Health Services Cost Review Commission by zip code of residence. Negative binomial regressions were used to determine associations between PH rates and LHPRs by race. Clusters of zip codes with high PH rates were assessed using the spatial Scan Statistic. ResultsPH rates were associated with family practitioners (IRR=0.98, 95% CI=0.97–0.99), physicians' assistants (IRR=0.98, 95% CI=0.96–0.99), internists (IRR=1.02, 95% CI=1.01–1.03), teaching hospitals (IRR=1.21, 95% CI=1.04–1.40), and local health departments (IRR=1.19, 95% CI=1.03–1.37). No LHPRs were associated with PHs among whites, but African American PH rates were associated with family practitioners (IRR=0.97, 95% CI=0.94–0.99), nurse practitioners (IRR=1.03, 95% CI=1.01–1.06), teaching hospitals (IRR=1.37, 95% CI=1.08–1.75) and gyms/recreational centers (IRR=0.85, 95% CI=0.73–0.99). Clusters of areas with high PH rates varied by race. African American PH clusters had fewer family practitioners and more federally qualified health centers and teaching hospitals. ConclusionsPublic health practitioners should look to LHPRs beyond physician supply or public clinics to address PHs, particularly among African Americans. Specific LHPRs could be used to target African American PH rates and clusters.

Resilience in Mothers of Very-Low-Birth-Weight Infants Hospitalized in the NICU

ObjectiveTo develop the theme of Resilience of mothers of very-low-birth-weight infants in the NICU from a qualitative study on maternal role attainment. DesignSecondary analysis using retrospective interpretation, that is, the further development and refinement of content related to resilience that was identified in the original data. SettingA tertiary NICU in Chicago. ParticipantsTwenty-three English-speaking, predominantly single (74%), minority (Black [57%], Hispanic [17%]), low-income (78%), primiparous (78%) mothers of very-low-birth-weight infants. MethodsNarrative analysis and core story creation were used to analyze the data related to resilience. A narrative of each participant's birth and NICU story was constructed and recurring meanings were analyzed. Identified patterns were compared across narratives to create one coherent core story that synthesized themes common to all stories. ResultsParticipants found meaning in redefining their priorities to become advocates for their infants and to “pick themselves up for their babies” by using resources that actively promoted their mental health. NICU-based breastfeeding peer counselors and bedside nurses helped guide participants through their NICU experiences, provided support so participants could gain confidence and competence, and allowed participants to cope with their long-term psychological distress. ConclusionParticipants demonstrated resilience as they learned to live with what was beyond their control. NICU nurses are ideally positioned to capitalize and expand on mothers' health-promoting strengths, resources, and coping strategies to help them further decrease their NICU-related stress and better integrate mothering behaviors into their lives long after NICU discharge.