Reply Hollie

Case study:

Health disparities a 32-year-old African American woman may experience related to her pregnancy, such as the risk for preterm labor and the high rate of infant mortality in low-income women.

           This is a timely topic as this year the CDC pointed out that the risk of black* women dying in pregnancy is three to four times that of white women (CDC, 2019). ACOG (2015) discusses the consistent and prevalent disparities in obstetrics and gynecology. Healthcare access is one of the documented issues. ACOG reminds us that the United States is the only country that has a market driven health care system rather than the view that healthcare is a right that every citizen should have (ACOG, 2015). In 2013, 59% of black women lived in areas where Medicaid was not going to be expanded (ACOG, 2015). Also documented is the biases and stereotyping from a provider point of view (ACOG, 2015). Demographic and social biases have been shown to influence clinican’s decisions regarding contraception and pre-natal care (ACOG, 2015). Could the mistrust of many black women with the healthcare system have anything to do with forced sterilization in the past? (ACOG, 2015).

These disparities are nothing new. In 2011, Cox, Zhang, Zotti, and Graham discussed racial disparities and unfavorable birth outcomes. The study referenced that fact that black women consistency received less than adequate pre-natal care from providers. In addition black women had a greater chance of premature babies, babies with low birth weight, and babies who die in childbirth (Cox, Zhang, Zotti, & Graham, 2011). We have the power, as Nurse Practitioners to encourage and provider early and consistent pre-natal care free of bias and judgment. With consistent care, we can assist with nutritional and psychosocial counseling as well as assisting with modifiable risk factors such as alcohol, drug use, or cigarette smoking in pregnancy (Cox, Zhang, Zotti, & Graham, 2011).

*I am African Canadian so prefer to use the word black rather than African American

References

American College of Obstetrics and Gynecology (ACOG). (2015). Women’s Health Care Physicians. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Racial-and-Ethnic-Disparities-in-Obstetrics-and-Gynecology

Centers for Disease Control (CDC). (2019). Pregnancy-Related Deaths | CDC. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm

Cox, R. G., Zhang, L., Zotti, M. E., & Graham, J. (2011). Prenatal care utilization in mississippi: Racial disparities and implications for unfavorable birth outcomes.Maternal and Child Health Journal, 15(7), 931-42. doi:http://dx.doi.org/10.1007/s10995-009-0542-6

Reply Gina

Given the United States’ climate of racial inequality and health disparities, our patient, which is an African American woman is more likely to be exposed to stress and complications such as preterm labor, preeclampsia, depression, fetal demise or fetal growth restriction during the pregnancy. A healthy environment, financial stability, healthcare, education, and social community context are essential during pregnancy (Mohamed et al., 2014). In this case study, the patient is a 32-years-old, African American single mother, has three children from previous relationships, is financially unstable, overweight, with preexisting conditions such as hypertension and at risk for gestational diabetes. She has two jobs that probably does not offer benefits or insurance coverage. The patient is more likely to experience hypertensive disorders of pregnancy that may be attributable to pre-pregnancy hypertension. Her BMI is already elevated, which may lead to complications, including preterm birth, fetal death, macrosomia, gestational diabetes, and cesarean delivery.

According to Mohamed et al. (2014), women of color are less likely to have access to vital reproductive health services including screening for sexually transmitted infections and cervical cancer, family planning; and abortion, when compared with non-Hispanic white women. Although socioeconomic status is considered the main leading factor in health disparities, factors at the patient, practitioner, and health care system levels contribute to existing and evolving disparities in women’s health outcomes (Mohamed et al., 2014). In this case, I would inquire on factors that contributed to her delay in OB care and lack of follow-up visits. What determined the patient to have all this gap in care? Was it the lack of financial resources or other factors such as domestic violence? Based on the screening results, the patient should be screened for domestic violence and guided in the process of care based on her needs and beliefs.

 Unfortunately, African American women receive lower-quality health care related to inequities in income, housing, education and job opportunities, which results in higher risk for mortality across the life span for this population (Bryant, 2010). This contributes to racial disparities in pregnancy-related risk factors such as hypertension, anemia, gestational diabetes, and obesity and other conditions such as heart disease, HIV, AIDS, and cancer (Bryant, 2010).

Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Studies showed that infants of African American mothers are more likely to be born preterm than infants of white mothers (Mohamed et al., 2014). But, why is preterm birth rate higher in African-Americans?

Women of color are 49 percent more likely than whites to deliver prematurely, and black infants are twice as likely as white babies to die before their first birthday (Mohamed et al., 2014). In this case, the stress, financial instability, lack of nutritional food, and comorbidities may put in jeopardy the patient and infant’s life. Although the Affordable Care Act (ACA) created historical advances in health insurance coverage, millions still go without health insurance each year, many of the people of color (Mohamed et al., 2014).

Low-income, lack of financial resources, maternal pre-pregnancy weight, exposure to stress, and maternal health status prior to pregnancy may lead to fetal growth restriction. Research showed that African American women are more likely to experience fetal growth restriction (FGR), a significant contributor to neonatal morbidity and mortality, than are women of other races and ethnicities (Bryant, 2010). The patient has to be enrolled in public programs such as the Special Supplemental Food Program for Women, Infants, and Children, to avoid food insecurity during pregnancy that may have a beneficial effect on FGR risk among women (Bryant, 2010).

According to Bryant (2010), there are multiple disparities in obstetrical outcomes between women of different race or ethnicities. The author suggests that stress induced by racial and gender discrimination plays a significant role in maternal and infant mortality. According to Kliff (2018), infants in the United States have a 76 percent higher risk of death compared with infants in other wealthy nations and African American women experience the most elevated rates of maternal and infant death. This inequity in health status can be reduced by properly addressing the social determinants of health and advocating for a system of more culturally and linguistically appropriate care for all. (Kliff, 2018).

In this case, it will be our responsibility as health care providers to encourage that all care is patient-centered, culturally appropriate, and listens to women’s needs. This new visit at the office represents a good opportunity for screening and education of the patient in a culturally sensitive manner about steps she can take to prevent disease conditions and any negative birth outcomes.

                                                         References

Bryant, A. S., Worjoloh, A., Caughey, A. B., & Washington, A. E. (2010). Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. American journal of obstetrics and gynecology, 202(4), 335-43.

Center for Reproductive Rights (2018). Addressing Disparities in Reproductive and Sexual Health Care in the U.S. Retrieved from https://www.reproductiverights.org/node/861

Mohamed, S. A., Thota, C., Browne, P. C., Diamond, M. P., & Al-Hendy, A. (2014). Why is Preterm Birth Stubbornly Higher in African-Americans? Obstetrics & gynecology international journal, 1(3), 00019.

Sarah Kliff (2018), American kids are 70 percent more likely to die before adulthood than kids in other rich countries, Retrieved from https://www.vox.com/health-care/2018/1/8/16863656/childhood-mortality-united-states.

PART 1: 4/4/19 SUBMISSION OF RESEARCH ARTICLE CRITIQUES Each student will write three research critiques from articles focused on research in healthcare informatics . The student should complete each critique utilizing the  . The critiques do not have to be written in narrative form. All critiques should be submitted as one  document. Requirements Title: Author(s): Purpose: Theoretical Framework: Population/Sample: Setting: Instrumentation (including validity and reliability): Research Design: Statistical Methods and Findings: (quantitative studies) Implications of the findings: Generalizability of the findings: (quantitative studies) Limitations:  Study recommendations:  Relevance of article research to your study: Bias:     

 PART 2: 4/14/19 SYNTHESIS OF RESEARCH ARTICLE CRITIQUES  –  The student will synthesize the information  contained in the three articles completed  for Part 1 of the assignment. The synthesis should be in written format utilizing APA style and conventions. The document should contain a title page, body (2-page minimum, 3 pages maximum), and reference page.

In a short essay (500-700 words), answer the Question at the end of Case Study 1. 

Cite references to support your positions.

Prepare this assignment according to the APA guidelines. An abstract is not required.

This assignment uses a grading rubric.

You are required to submit this assignment to LopesWrite

RUBRIC

1. Identification of anemia classification and rationale is offered in detail, while demonstrating evidence of deeper insight and/or reflection. 40%

2. Explanation of patient diagnosis uses outside sources and/or medical and nursing references to support conclusions and is offered in detail, while demonstrating evidence of deeper insight and/or reflection. 40%

3. Thesis and/or main claim are comprehensive; contained within the thesis is the essence of the paper. Thesis statement makes the purpose of the paper clear. 5%

4. There is a sophisticated construction of paragraphs and transitions. Ideas progress and relate to each other. Paragraph and transition construction guide the reader. Paragraph structure is seamless 5%

5. Writer is clearly in command of standard, written, academic English. 5%

6. All format elements are correct. 2%

7. In-text citations and a reference page are complete. The documentation of cited sources is free of error. 3%

CASE STUDY IS ATTACHED

Respond to the post bellow in one or more of the following ways:

Ask a probing question, substantiated with additional background information, and evidence.

Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.

Offer and support an alternative perspective using readings from  the classroom or from your own review of the literature in the Walden  Library.

Validate an idea with your own experience and additional sources.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.

                                             Main Post

 An Intervention Program to Promote Health-Related Physical Fitness in Nurses

             This quantitative, quasi-experimental study conducted by Yaun et al.  (2009) aimed to determine the effects of an exercise intervention on  nurses’ health-related physical fitness. The researchers also expressed  an explicit interest in the relationship between physical fitness and  the incidence of musculoskeletal disorders. Taiwanese nurses from five  different units volunteered to be part of the study. The participants  were divided into two groups with 45 nurses in the experimental group  and 45 nurses in the control group. There was no randomization, but all  the participants gave written informed consent (Yaun et al., 2009). 

Internal Validity 

             According to Polit and Beck (2017), internal validity pertains to the  empirical relationship between the independent variable and the final  results. Researchers must establish that the intended cause created the  effect, and that it was not influenced by other variables (Polit &  Beck, 2017). After all, correlation does not equal causation, and an  astute researcher will adeptly identify and control convoluting  variables. Further, Andrade (2018) asserts that internal validity  assesses whether the design of the study, the conduct of the  researchers, and the analysis of the results answer the research  question without bias (Andrade, 2018). 

Consequently,  the research conducted by Yaun et al. did have some issues that  negatively impacted the internal validity of their research. Firstly,  convoluting variables were not adequately controlled. The exclusion  criteria consisted of cardiovascular disease, diabetes, hypertension,  renal disease, pulmonary disease, severe musculoskeletal aches, and  pregnancy. However, other significant variables such as age, gender,  marital status, educational level, or other medical issues. It is worth  noting that the diet and exercise habits of the participants were not  limited by the researchers.

Moreover,  the nurses in the experimental group worked a fixed schedule whereas  nurses in the control group worked alternating shifts. Secondly, the  lack of randomization coupled with the fact that the participants worked  for the same organization could have contaminated the results. Thirdly,  while the results of the research showed the exercise intervention  improved the physical fitness of the participants in the experimental  group, participants were not evaluated for musculoskeletal  improvements.   

Recommendations to Strengthen Internal Validity

A  different research design would have strengthened internal validity.  Randomization is the most effective way to control individual  characteristics of participants. Randomization also eliminates for the  Hawthorne Effect, which occurs when participants behave differently  because they know they are being studied. Moreover, a cross-over design  is highly effective when groups are being compared to one another.  Although, this design is subject to carryover bias, in which an effect  carries over from one experimental condition to another (Polit &  Beck, 2017). 

I  contend that a randomized control trial with a cross over design would  have increased the strength of the internal validity in this study. In a  cross-over design participants serve as their own control group, which  would negate the convoluting variables that influenced the results of  this study, and would more accurately gauge changes resulting from the  exercise intervention. I would also add a metric to assess the  musculoskeletal status of the participants. To limit the effects of  carryover bias, the health metrics of the participants would be obtained  before the exercise intervention to establish a baseline, then after  the exercise intervention, and finally, after a wash-out period, the  metrics should be re-recorded.

The Impact of Changes on Other types of Validity 

In  contrast to internal validity, statistical validity is not concerned  with the causal relationship between variables, but rather measures the  mathematical correlation of all relationships that occur between the  variables (Polit & Beck, 2017). The randomized control, crossover  design would improve statistical validity because the participants would  serve as their own control group making statistical analysis more  powerful. Construct validity determines if the outcome measured  corresponds to the theoretical construct of the study (Polit & Beck,  2017). In this research, the theoretical construct was Pender’s health  promotion model. Construct validity also would have been improved by  changing the design of the study. The same health promotion strategy  yields different outcomes for different participants based on individual  differences. The modification of the study’s design would have negated  these individual differences. External validity indicates if the results  of the research will remain the same when applied to other people or  settings (Polit & Beck, 2017). Again, a change in the design of this  research would optimize external validity which would increase the  likelihood of the results influencing evidence-based practice.

Failure to Consider Validity in Research

Failing  to properly account for and control variables threatens the validity of  the results yielded from the research. The rigor of the research design  may be the most important factor in strengthening or weakening  validity, as evidenced by the hierarchy of research studies in the  evidentiary pyramid. Other elements such as biased statistical analysis,  unreliable implementation of an intervention, carryover bias, and the  Hawthorne Effect are just a few variables that can threaten the validity  of a research study (Polit & Beck, 2017). Since research guides  evidence-based practice, failure to ensure the validity of results  directly affects patient outcomes; unfortunately, the effects of poorly  executed research impacts all research. People are inherently inclined  to remember negative consequences over positive outcomes. Improper  research regarding vaccines has created an anti-vaccination movement  that is highly problematic. Big tobacco companies produced improper  research that may have resulted in people continuing to smoke longer  than they otherwise would have. The failure to appropriately consider  validity in research is a grave mistake that should be avoided at all  costs. 

References 

Andrade, C. (2018). Internal, external, and ecological validity in research design, conduct, and evaluation. Indian Journal of Psychological Medicine,40(5), 498. doi:10.4103/ijpsym.ijpsym_334_18

Polit, D. F., & Beck, C. T. (2017). Nursing research generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer.

Yuan,  S., Chou, M., Hwu, L., Chang, Y., Hsu, W., & Kuo, H. (2009). An  intervention program to promote health-related physical fitness in  nurses. Journal of Clinical Nursing,18(10), 1404-1411. doi:10.1111/j.1365-2702.2008.02699.x