Sequential Mixed Methods Study Research Articles

Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation tool for rigor in mixed methods implementation research.

Implementation science helps generate approaches to expedite the uptake of evidence in practice. Mixed methods are commonly used in implementation research because they allow researchers to integrate distinct qualitative and quantitative methods and data sets to unravel the implementation process and context and design contextual tools for optimizing the implementation. To date, there has been limited discussion on how to ensure rigor in mixed methods implementation research. To present Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation (PEARL) as a practical tool for understanding various components of rigor in mixed methods implementation research. This methodological discussion is based on a nurse-led mixed methods implementation study. The PEARL tool was developed based on an interpretive, critical reflection, and purposive reading of selected literature sources drawn from the researchers' knowledge, experiences of designing and conducting mixed methods implementation research, and published methodological papers about mixed methods, implementation science, and research rigor. An exemplar exploratory sequential mixed methods study in nursing is provided to illustrate the application of the PEARL tool. The proposed tool can be a useful and innovative tool for researchers and students intending to use mixed methods in implementation research. The tool offers a straightforward approach to learning the key rigor components of mixed methods implementation research for application in designing and conducting implementation research using mixed methods. Rigorous implementation research is critical for effective uptake of innovations and evidence-based knowledge into practice and policymaking. The proposed tool can be used as the means to establish rigor in mixed methods implementation research in nursing and health sciences.

Evaluation and students’ perception of a health equity education program in physical therapy: a mixed methods pilot study

BackgroundHealth equity is a common theme discussed in health professions education, yet only some researchers have addressed it in entry-level education.PurposeThe purpose of this study is to serve as an educational intervention pilot to 1) evaluate students’ perception of the effectiveness of the DPT program in providing a foundation for health equity education, with or without the benefit of a supplemental resource and 2) establishing priorities for the program related to educating students on health inequities in physical therapy clinical practice.A mixed method design with a focus-group interview was utilized to explore students’ perceptions of the DPT program's commitment to advancing health equity.MethodsA three-staged sequential mixed methods study was conducted. Stage 1 began with quantitative data collection after completing the DEI Bundle utilizing the Tripod DEI survey. Stage 2 involved identifying themes from the Tripod Survey data and creating semi-structured interview questions. Stage 3 consisted of a focus group interview process.ResultsA total of 78 students completed the Tripod DEI survey upon completing 70% of the curriculum. Thirty-five students, eight core faculty, 13 associated faculty, and four clinical instructors completed the APTA DEI Bundle Course Series. According to the Tripod DEI Survey results, program stakeholders found the program’s commitment to DEI and overall climate to be inclusive, fair, caring, safe, welcoming, and understanding of individuals from different backgrounds, including a sense of student belonging where students feel valued and respected. Three themes emerged from the qualitative focus group interviews, including the value of inclusivity, health equity curricular foundations, and DEI in entry-level DPT education.ConclusionsThis study highlights the value of incorporating health equity and DEI topics into curricula while fostering an incluse program culture.

Stressed Out: Identifying Inequities and Underlying Causes Associated With Pre-med Student Stress

Stress is among the top mental health concerns of US college students and hypothesized to be especially high among pre-med students. Yet, the extent to which pre-meds’ stress differs from other college science students’ stress, as well as the underlying factors contributing to pre-meds’ stress are understudied. Given that stress is disproportionately likely to impact students who are already underrepresented and underserved in science and medicine, it is integral to identify what underlies student stress. Study Objective: We conducted a sequential mixed-methods study to identify what factors exacerbate pre-med stress and the severity of pre-med stress compared to students who are not pre-med. Hypothesis: We hypothesized the competitive nature of being pre-med would account for the majority of pre-med stress and that their overall stress levels would be higher than those of their counterparts. Methods: In Study 1, we conducted an exploratory qualitative interview study with 30 undergraduate pre-meds to assess what aspects of being pre-med exacerbate their stress. We built on this work in Study 2, with a survey of 551 science undergraduates to (a) assess how generalizable the findings from Study 1 were among undergraduate pre-meds at scale and to (b) assess whether students with different career tracks express different levels of stress. Our specific research questions were: 1) On average, do students perceive that pre-meds have higher stress than non-pre-med science majors? 2) Do pre-meds report higher levels of academic stress, perfectionism, social comparison, and perceived competitive environment in science college courses? 3) What aspects of being pre-med induce stress? and 4) What recommendations do pre-meds have for instructors and institutions to decrease pre-med stress? We used open coding methods and regressions to analyze our data. Results: We found that most students perceived that pre-med students had higher stress than their peers. However, while pre-meds reported higher levels of social comparison, they did not express higher academic stress, perfectionism, or perceived competition compared to their peers in science. Regardless of career path, being a woman or non-binary, identifying as a person excluded because of their ethnicity or race (PEER), financially unstable and having a lower GPA significantly predicted a higher academic stress score. Aspects of the medical school application underlying pre-med stress include worrying about not being good enough or maintaining a competitive GPA. Conclusion: This study highlights the levels of stress among pre-meds do not differ compared to non-pre-med science undergraduates, but that women or non-binary students, PEERs, students who are financially unstable and those with lower GPAs are more likely to experience stress in the context of undergraduate science. This work provides student-produced recommendations for ways in which instructors and institutions can decrease the stress associated with being a pre-med student. This study was funded by an ASU Online Undergraduate Research Scholars program seed grant. Graduate student Mohammed is funded by an NSF GRFP #026257-001 and PI Cooper is funded by an NSF CAREER #2143671. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Development and psychometric evaluation of "Caring Ability of Mother with Preterm Infant Scale" (CAMPIS): a sequential exploratory mixed-method study.

Caring ability is one of the most important indicators regarding care outcomes. A valid and reliable scale for the evaluation of caring ability in mothers with preterm infants is lacking. The present study was conducted with the aim of designing and psychometric evaluation of the tool for assessing caring ability in mothers with preterm infants. A mixed-method exploratory design was conducted from 2021 to 2023. First the concept of caring ability of mothers with preterm infants was clarified using literature review and comparative content analysis, and a pool of items was created. Then, in the quantitative study, the psychometric properties of the scale were evaluated using validity and reliability tests. A maximum likelihood extraction with promax rotation was performed on 401 mothers with the mean age of 31.67 ± 6.14years to assess the construct validity. Initial caring ability of mother with preterm infant scale (CAMPIS) was developed with 64 items by findings of the literature review, comparative content analysis, and other related questionnaire items, on a 5-point Likert scale to be psychometrically evaluated. Face, content, and construct validity, as well as reliability, were measured to evaluate the psychometric properties of CAMPIS. So, the initial survey yielded 201 valid responses. The three components: 'cognitive ability'; knowledge and skills abilities'; and 'psychological ability'; explained 47.44% of the total observed variance for CAMPIS with 21 items. A subsequent survey garnered 200 valid responses. The confirmatory factor analysis results indicated: χ2/df = 1.972, comparative fit index (CFI) = 0.933, and incremental fit index (IFI) = 0.933. These results demonstrate good structural, convergent, discriminant validity and reliability. OMEGA, average inter-item correlation (AIC), intraclass correlation coefficients (ICC) for the entire scale were at 0.900, 0.27 and 0.91 respectively. Based on the results of the psychometric evaluation of CAMPIS, it was found that the concept of caring ability in the Iranian mothers with preterm infants is a multi-dimensional concept, which mainly focuses on cognitive ability, technical ability, and psychological ability. The designed scale has acceptable validity and reliability characteristics that can be used in future studies to assess this concept in the mothers of preterm infants.

Metacognitive Strategies for Mathematical Modeling with Engineering Groups of Students: Adaptation and Validation of a Questionnaire

A sequential exploratory mixed-methods study is implemented to develop an instrument that allows for the evaluation of the metacognitive strategies used by engineering groups of students when solving mathematical modeling problems. The findings of the qualitative study guided by observations and interviews reveal the use of metacognitive strategies of ‘planning’, ‘monitoring and, if necessary, regulation’, and ‘evaluation’. In this article, we present the final categories of the qualitative analysis and discuss how these data were shaped into a theoretical construct and items of an instrument to measure metacognitive strategies. The psychometric properties of the instrument are analyzed, and it is argued that it has a similar interpretation among males and females, as there are no significant differences in these results. The development of the present study demonstrates how the qualitative method can support the adaptation of an instrument to measure metacognitive strategies, thus contributing to validity and applicability.

Validation and measurement properties of the Male and Female Fertility Knowledge Inventories (MFKI and FFKI) in Iranian couples

BackgroundOne of the most important population challenges during the last three decades has been the significant decrease in the fertility rate worldwide. Since the validity and reliability of the Male and Female Fertility Knowledge Inventories (MFKI and FFKI) have not been determined in Iran, we conducted this study to assess psychometric characteristics of the MFKI and FFKI in couples in Tabriz and Urmia, Iran.MethodsThis was a cross-sectional study, as the first part (quantitative phase) of a sequential explanatory mixed-method study. The current study was done on 1200 participants (600 women with their husbands) living in the northwestern region of Iran, between January 2023 and September 2023. The psychometric properties of the Persian version of the tool (MFKI and FFKI) were performed in 5 stages, including translation process, content validity, face validity, construct validity and reliability assesment.ResultsIn this study, the CVI, CVR, and impact scores of the MFKI tool were equal to 0.90, 0.88, 3.26 and CVI, CVR, and Impact scores of the FFKI tool were respectively equal to 0.95, 0.91 and 3.59, that it indicated a satisfactory level of content and face validity. Then, to check the construct validity, the results of the exploratory factor analysis of the MFKI tool on 13 items led to the identification of 3 factors, including Environment and reproductive health (ERH), Lifestyle factors (LSF) and Sperm quality (SQ), which explained 66% of the cumulative variance. The results of the exploratory factor analysis of the FFKI tool on 15 items led to the identification of 4 factors, including Reproductive health (RH), Lifestyle factors (LSF), Chance of conception (CHC) and Ovarian reserve and preservation (ORP), which explained 68% of the cumulative variance.ConclusionsThe findings of this study indicated that the Persian version of MFKI and FFKI has acceptable psychometric properties to measure the awareness of Iranian couples regarding fertility, which can be used as a screening tool for fertility knowledge by health care professionals and also as a reliable tool in research.

Midwives’ experiences with PPE during the COVID-19 pandemic: The Birth in the Time of COVID (BITTOC) study

BackgroundThe COVID-19 pandemic resulted in rapid changes aimed at reducing disease transmission in maternity services in Australia. An increase in personal protective equipment (PPE) in the clinical and community setting was a key strategy. There was variation in the type of PPE and when it was to be worn in clincial practice. AimThis paper reports on Australian midwives’ experiences of PPE during the pandemic. MethodsThis sequential mixed methods study was part of the Birth in the Time of COVID-19 (BITTOC 2020) study. Data were obtained from in-depth semi-structured interviews with midwives in 2020 followed by a national survey undertaken at two time points (2020 and 2021). Qualitative open-text survey responses and interview data were analysed using content analysis. Findings16 midwives were interviewed and 687 midwives provided survey responses (2020 n = 477, 2021 n = 210). Whilst midwives largley understood the need for increased PPE, and were mainly happy with this, as it was protective, they reported a number of concerns. These included: inconsistency with PPE type, use, availability, quality, fit and policy; the impact of PPE on the physical and psychological comfort of midwives; and the barriers PPE use placed on communication and woman centred care. This at times resulted in midwives working outside of policy. ConclusionThese findings highlight the need for future comprehensive pandemic preparedness that ensures policy and procedure recommendations are consistent and PPE is available, of approriate quality, and individually fitted in order to ensure that Australian maternity services are well placed to manage future pandemics.

Video Strategy as Scaffolding to Foster Students’ Grammar Proficiency and Writing Skills in EFL Learning

Despite its significance particularly when it comes to writing competence, numerous studies have revealed that grammar is still considered complicated to grasp and used by students. The purpose of this study was to determine how video-based instruction affects students' understanding of grammar in writing assignments. This sequential explanatory mixed-method study aimed to investigate how students' grammatical skills especially in degree of comparison might be improved. Quantitative evaluations such as creating written test materials for the students and qualitative interviews with both teachers and students were employed. The findings showed that students' comprehension of grammatical rules for statistical tests had improved. Descriptive data evidenced that the students were clearly excited, enthralled, and actively involved with the tactics; served as a scaffold to lower obstacles; enhanced language learners' understanding; and increased students' vocabulary. Both quantitative and qualitative approaches evidenced the significance of implementing English videos to promote students’ grammatical competence in writing skills. The study's implications and suggestions are discussed.

The design and evaluation of gamified online role-play as a telehealth training strategy in dental education: an explanatory sequential mixed-methods study

To evaluate user perceptions and educational impact of gamified online role-play in teledentistry as well as to construct a conceptual framework highlighting how to design this interactive learning strategy, this research employed an explanatory sequential mixed-methods design. Participants were requested to complete self-perceived assessments toward confidence and awareness in teledentistry before and after participating in a gamified online role-play. They were also asked to complete a satisfaction questionnaire and participate in an in-depth interview to investigate their learning experience. The data were analyzed using descriptive statistics, paired sample t-test, one-way analysis of variance, and framework analysis. There were 18 participants who completed self-perceived assessments and satisfaction questionnaire, in which 12 of them participated in a semi-structured interview. There were statistically significant increases in self-perceived confidence and awareness after participating in the gamified online role-play (P < 0.001). In addition, the participants were likely to be satisfied with this learning strategy, where usefulness was perceived as the most positive aspect with a score of 4.44 out of 5, followed by ease of use (4.40) and enjoyment (4.03). The conceptual framework constructed from the qualitative findings has revealed five key elements in designing a gamified online role-play, including learner profile, learning settings, pedagogical components, interactive functions, and educational impact. The gamified online role-play has demonstrated its potential in improving self-perceived confidence and awareness in teledentistry. The conceptual framework developed in this research could be considered to design and implement a gamified online role-play in dental education. This research provides valuable evidence on the educational impact of gamified online role-play in teledentistry and how it could be designed and implemented in dental education. This information would be supportive for dental instructors or educators who are considering to implement teledentistry training in their practice.

The Effect of Group-Individual Collaborative Testing on Primary Students’ Achievement in Reading Test

Collaborative testing—a two-stage testing modality in which students do tests as a group and individually—has been extensively researched and found to improve learning. However, most collaborative testing research has focused on non-English language learning. Therefore, this study examines the effects of group-individual collaborative testing (GICT) on English reading test achievement and student views of GICT. This sequential explanatory mixed-methods study gathered quantitative data from both treatment and control groups, primarily comprising students' correct answers, followed by qualitative insights derived from students' reflections on their learning experiences. Quantitative data demonstrates that GICT had a significant effect on students' reading achievement tests. While the qualitative data reveals that students considered GICT was a good reading testing modality, with some notes on the scoring method. Practice and research implications include 1) using GICT to test other language skills, 2) diversifying group composition, 3) giving more weight to the individual part score because students will retrieve more information during this stage, and 4) instilling collaborative learning values before testing.

The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study

BackgroundClarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study.MethodsThe present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts’ opinions and results of the AGREE II tool.ResultsThe guideline included the items for evaluating the severity of obstetric symptoms at five levels including “critical”, “urgent”, “less urgent”, “no urgent”, and “recommendations”. The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively.ConclusionThe OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.

Double-duty caregivers enduring COVID-19 pandemic to endemic: "It's just wearing me down".

The COVID-19 pandemic has considerably strained health care providers and family caregivers. Double-duty caregivers give unpaid care at home and are employed as care providers. This sequential mixed-method study, a survey followed by qualitative interviews, aimed to comprehensively understand the experiences of these Canadian double-duty caregivers amidst the pandemic and the transition to the endemic phase. The multi-section survey included standardized assessments such as the Double-duty Caregiver Scale and the State Anxiety Scale, along with demographic, employment-related, and care work questions. Data analysis employed descriptive and linear regression modeling statistics, and content analysis of the qualitative data. Out of the 415 respondents, the majority were female (92.5%) and married (77.3%), with 54.9% aged 35 to 54 years and 29.2% 55 to 64 years. 68.9% reported mental health decline over the past year, while 60.7% noted physical health deteriorated. 75.9% of participants self-rated their anxiety as moderate to high. The final regression model explained 36.8% of the variance in participants' anxiety levels. Factors contributing to lower anxiety included more personal supports, awareness of limits, younger age, and fewer weekly employment hours. Increased anxiety was linked to poorer self-rated health, and both perceptions and consequences of blurred boundaries. The eighteen interviewees highlighted the stress of managing additional work and home care during the pandemic. They highlighted the difficulty navigating systems and coordinating care. Double-duty caregivers form a significant portion of the healthcare workforce. Despite the spotlight on care and caregiving during the COVID-19 pandemic, the vital contributions and well-being of double-duty caregivers and family caregivers have remained unnoticed. Prioritizing their welfare is crucial for health systems as they make up the largest care workforce, particularly evident during the ongoing healthcare workforce shortage.

“I have come to remove it because of heavy bleeding”: a mixed-methods study on early contraceptive implant removal and the underlying factors in eastern Uganda

BackgroundEarly contraceptive implant removal without intentions to conceive predisposes women to unintended pregnancies.. Some of the unintended pregnancies end in unsafe abortions which further increases the risk of maternal mortality and morbidity. Therefore, we assessed the proportion of women who had early contraceptive implant removal. We also explored the reasons for early contraceptive implant removalamong women at Mbale Regional Referral Hospital in eastern Uganda.MethodsWe conducted a sequential explanatory mixed methods study at Mbale Regional Referral Hospital between November 2022 to December 2022. For quantitative data, we performed a secondary analysis on data extracted from the integrated family planning registers. We used systematic random sampling to select 600 clients’ serial numbers from the registers. The outcome variable was early contraceptive implant removal defined as removal of the implant by the woman before 18 months from the time of insertion. For qualitative data, we conducted 11 in-depth interviews among women who had come for contraceptive implant removal at the family planning clinic. We also conducted two key informant interviews with midwives working at the family planning unit. Quantitative data were analysed using Stata version 14.0 (Stata Corp LLC, College Station, Texas, USA) while qualitative data were analysed by thematic content analysis.ResultsIn this study, 15% (91/600) of the women discontinued contraceptive implants within 12 months, 29% (175/600) within 18 months, 38% (230/600) within 24 months and 40% (240/600) within 36 months of insertion. Among the women who discontinued contraceptive implant use, only 6.7% (40/600) switched to another family planning method. Out of the 175 women who removed contraceptive implants early, side effects 61.1% (107/175) desire to conceive 53.1% ( 93/175),, and gender-based violence 8.6% (15/175) were the major reasons for removal. From the qualitative interviews, the major reasons for early contraceptive implant removal were side effects such as heavy menstrualbleeding.Conclusion A third of women discontinued contraceptive implant use within 18 months. Addressing concerns regarding side effects and male partner disapproval of modern contraceptives may improve continued use of implants.

Characteristics for Medical Cannabis Treatment Adherence among Autistic Children and Their Families: A Mixed-Methods Analysis

Introduction: Medical cannabis treatment for autistic children has recently become popular, and studies have focused on examining the treatment’s effects on children’s symptom presentation, reported side effects, and dropout rates. However, no previous study has investigated the factors influencing adherence and dropout rates in cannabis treatment. Method: This explanatory sequential mixed-methods study explored these factors by examining the characteristics of 87 autistic children and their families and deepening parents’ perspectives and experiences of the 6-month CBD-rich cannabis treatment’s benefits and barriers. Results: We found this treatment to have a high (75%) adherence rate, relatively mild side effects, and substantial reported benefits for the children and families. However, this treatment was not free of barriers; the intake regime, some side effects, and in some cases, unrealistic parental expectations made adherence difficult for some families. Conclusion: Our results highlight the importance of providing professional guidance and knowledge to parents of autistic children, enhancing their understanding of the impact of CBD-rich cannabis treatment on their children and expected related challenges, and coordinating realistic treatment expectations. We hope that addressing these important aspects will influence parents’ ability to adhere to and enjoy the benefits of cannabis treatment for their autistic children.

Barriers to and Facilitators of Pediatric Vaccination Reporting in Four US States, 2023.

In a 2023 sequential explanatory mixed-methods study in four US states, we identified barriers and facilitators experienced by Vaccines for Children (VFC) program providers in reporting vaccination data to state immunization information systems (IISs). We found the following: VFC providers value accurate, robust, and widely used IISs. IIS reporting is easier with but does not require an electronic health record. Negative interactions with IISs and VFC officials and limited practice capacity are barriers to reporting. The COVID-19 pandemic highlighted the need for a nationwide vaccination database. (Am J Public Health. 2024;114(6):569-574. https://doi.org/10.2105/AJPH.2024.307638).

Oncology's Silent Caregivers: A Mixed-Methods Exploration of the Experiences, Outcomes, and Unmet Needs of Caregiving Youth of a Parent With Cancer.

Cancer affects the whole family system causing reorganization of functioning and responsibilities where children may take on a caregiving role. In the United States, an estimated 204 000 to 475 000 caregiving youth provide multifaceted, extended care in oncology. This results in both positive and negative outcomes for youth-spanning multiple domains of health. The aim of this study was to explore the caregiving experiences, outcomes, and unmet needs of caregiving youth (aged 12-24 years) in oncology. An explanatory sequential mixed-methods study design was used. Fifty-two adults who lived with a parent with cancer as a child were recruited via social media and asked to complete an online survey. A subsample of 18 individuals reporting high to very high amounts of caregiving were subsequently interviewed. The mean reported caregiving youth age was 16.13 (±4.86) years. They provided care approximately 22.43 h/wk for approximately 3.04 years. Most (71.2%) reported high to very high amounts of caregiving activity. The highest reported categories of unmet needs were information, family, feelings, friends, and time out/recreation. Qualitative findings included 4 themes: stepping into the role, family communication, dealing with feelings, and a new separateness. Identified needs included a desire for more information to aid in uncertainty, better communication within the family, needing someone to help them process their feelings, and peer-to-peer support. It is important for nurses and researchers to be aware of and acknowledge the needs of families dealing with cancer and aid in the development and implementation of tailored interventions to support caregiving youth.

U.S. Men’s Sheds: Promoting Meaning, Purpose, and Connection

ABSTRACT The purpose of this study was to explore U.S. Men’s Sheds, learn how they operate, who attends them, and how participants perceived sheds. It is the first study exploring Men’s Sheds in the U.S. An explanatory sequential mixed methods study was conducted, and paper-based surveys were sent to sheds registered with the U.S. Men’s Sheds Association. Shed chairpersons encouraged members to complete surveys (N = 76), and results showed that most members were male, older adults, in good health, and joined to make new friends or learn new skills. Four in-depth interviews were also conducted and revealed men participated to give back to their community but at times disagreed on the best way to do so. Some members were focused on sharing their religious beliefs with others whereas others were interested in rebuilding structures in the community. U.S. Men’s Sheds provide members with benefits by providing a sense of continued purpose and engagement. Overall, participants joined because they wanted something worthwhile to do with their time, especially retired men. Future researchers should conduct other interviews with Men’s Sheds members in the U.S. to provide additional insight into shed operations and the activities they are involved in.

The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis

BackgroundPeople worldwide are concerned with the possibility of climate change, microplastics, air pollution, and extreme weather affecting human health. Countries are implementing measures to reduce environmental impacts. Nurses play a vital role, primarily through Green Teams, in the process of promoting sustainable practices and minimizing the environmental footprint of health care facilities. Despite existing knowledge on this topic, assessing nurses’ environmental awareness and behavior, including the barriers they face, is crucial with regard to improving sustainable health care practices.AimTo analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to the creation of a sustainable environment.MethodsA sequential mixed-method study was conducted to investigate Spanish nurses. The study utilized an online survey and interviews, including participant observation. An online survey was administered to collect quantitative data regarding environmental awareness and behavior. Qualitative interviews were conducted with environmental nurses in specific regions, with a focus on Andalusia, Spain.ResultsMost of the surveyed nurses (N = 314) exhibited moderate environmental awareness (70.4%), but their environmental behavior and activities in the workplace were limited (52.23% of participants rarely performed relevant actions, and 35.03% indicated that doing so was difficult). Nurses who exhibited higher levels of environmental awareness were more likely to engage in sustainable behaviors such as waste reduction, energy conservation, and environmentally conscious purchasing decisions (p < 0.05). Additionally, the adjusted model indicated that nurses’ environmental behavior and activities in the workplace depend on the frequency of their environmental behaviors outside work as well as their sustainable knowledge (p < 0.01). The results of the qualitative study (N = 10) highlighted certain limitations in their daily practices related to environmental sustainability, including a lack of time, a lack of bins and the pandemic. Additionally, sustainable environmental behavior on the part of nursing leadership and the Green Team must be improved.ConclusionsThis study revealed that most nurses have adequate knowledge, attitudes, and behaviors related to environmental sustainability both inside and outside the workplace. Limitations were associated with their knowledge and behaviors outside of work. This study also highlighted the barriers and difficulties that nurses face in their attempts to engage in adequate environmental behaviors in the workplace. Based on these findings, interventions led by nurses and the Green Team should be developed to promote sustainable behaviors among nurses and address the barriers and limitations identified in this research.Graphical

Climate change and health: The case of mapping droughts and migration pattern in Iran (2011-2016).

Migration and mobility of population have been reported as a common reaction to drought. There is historical evidence to suggest the health effects of droughts and human migration linkage in Iran. This study aimed to map the drought and migration patterns in Iran in 2011 and 2016 and explore their possible health impacts. This sequential explanatory mixed-method study was done in two stages of spatial analysis and qualitative study. Data mapping was conducted through the equal interval classification and using drought, migration, and agriculture occupation data based on provincial divisions in Iran in 2011 and 2016. This qualitative study was conducted using the content analysis approach. The in-migration rate was higher in 2011 rather than 2016. Migration to cities was much higher than migration to villages in both years. The frequency of male migrants was higher than females in all provinces in 2011 and 2016. Physical and mental diseases as well as economic, sociocultural, education, and environment effects on health were extracted from the qualitative data. A holistic picture of droughts and migration issues in Iran and their health consequences were achieved by the present research. Further research is needed to explore the determinants of health impacts of climate change in vulnerable groups. Public health problems can be prevented by adaptive and preventive policy-making and planning. This can improve the coping capacity of the population facing droughts and enforced migration.

Treatment fatigue among adult patients with chronic heart failure in a tertiary care hospital in Ethiopia: a mixed-methods study

Background/Aims Patients with heart failure must adhere to strict treatment regimens, including pharmacological treatments, medical appointments and lifestyle modifications. This study aimed to assess the extent of treatment regimen fatigue among patients with heart failure in Ethiopia and identify factors that may exacerbate this. The authors also aimed to gather insights from patients and health professionals about how to ameliorate the impact of treatment regimen fatigue. Methods An explanatory sequential mixed-methods study was conducted at a specialist cardiac clinic in Ethiopia from 1 August to 30 September 2021. In the quantitative stage, the Treatment Regimen Fatigue Scale was delivered via interview to 325 patients with heart failure to collect data on their level of treatment regimen fatigue and analyse this against their demographic, clinical and treatment-related characteristics. The influences of factors on treatment regimen fatigue were tested using the Mann–Whitney U, Kruskal–Wallis and Chi square tests, as appropriate. In the qualitative stage, interviews were conducted with 14 patients with heart failure and 10 specialist health professionals to identify possible interventions to reduce treatment regimen fatigue. Interviews were recorded, transcribed and subject to content analysis to identify themes. Results In the quantitative phase, participants' mean level of treatment regimen fatigue was −48.38±13.1, indicating low levels of fatigue. Several factors had a significant impact on level of treatment regimen fatigue, including living alone (U=7819.5; Z=−3.01; P=0.003); poor knowledge of heart failure (U=4379.0; Z=−4.24; P&lt;0.001); lack of family support (U=6152.5; Z=−4.09; P&lt;0.01); presence of two or more comorbidities (U=11273.5; Z=−2.28; P=0.023); adverse drug effects (U=6990.0; Z=−2.78; P=0.006); poor availability of medications (U=10215.0; Z=−3.43; P=0.001); and reliance on health insurance to obtain medication (X2=7.18; P=0.028). Qualitative results indicated that improving patients' self-care, making changes to the structure of the cardiac clinic (eg more regular follow up with the same clinician) and improving the general healthcare system could reduce treatment regimen fatigue. Conclusions Patients with heart failure seem to experience low levels of treatment regimen fatigue, but this can be influenced by a variety of demographic, clinical and treatment-related factors. Interventions on a local and systemic level could reduce the risk of treatment regimen fatigue, but there is no one-size-fits-all solution.