This research is an anthology of a series of papers intended to describe the health state, healthcare experiences, healthcare preventive practice, healthcare barriers, and cardiovascular disease (CVD) risk factors of Asian Americans (AA) residing in Arizona (AZ). Asian Americans are known to be vulnerable populations and there is paucity of data on interventions to reduce CVD risk factors. An extensive literature review showed no available disaggregated health data of AA in AZ. The Neuman Systems Model guided this study. Chapter 1 elucidates the importance of conducting the research. It provides an overview of the literature, theory, and methodology of the study. Chapters 2 and 3 describe the results of a cross-sectional descriptive secondary analysis using the 2013, 2015, and 2017 Behavior Risk Factor Surveillance System (BRFSS) datasets. The outcomes demonstrate the disaggregated epidemiological phenomenon of AA. There were variations in their social determinants of health, healthcare barriers, healthcare preventive practice, CVD risk factors, and healthcare experiences based on perceived racism. It highlighted modifiable and non-modifiable predictors of hypertension (HTN) and diabetes. Chapter 4 is an integrative review of interventions implemented to reduce CVD risks tailored for Filipino Americans. Chapter 5 summarizes the research findings. The results may provide the community of practicing nurses, researchers, and clinicians the evidence to plan, prioritize, and implement comprehensive, theoretically guided, and culturally tailored community-led primary and secondary prevention programs to improve their health outcomes. The data may serve as a tool for stakeholders and policy makers to advocate for public health policies that will elevate population health of AA or communities of color in AZ to be in line with non-Hispanic White counterparts.

The number of refugees experiencing displacement is 25.9 million worldwide, with the majority in the last 7 years from Syria. While international government organizations and researchers have called for assessment of refugee health and wellness, research in this vulnerable population is limited. This dissertation is built around humanizing refugee research on health and wellness. The introduction in Chapter 1 provides an overview for the three resulting chapters which are (a) a grounded theory study to gain insight into the lives of Syrian refugees living in displacement; (b) a systematic literature review on wellness in Syrian refugees in displacement; and (c) a concept analysis to examine wellness from the perspective of Syrian refugee women within the context of displacement. Chapter 5 includes the summary, discussion, and recommendations for future research.

Chapter 2 consists of three themes which shaped the lives of Syrian refugees during displacement: (a) assets and deficits; (b) official obstacles and supports; and (c) unofficial obstacles and supports. Health emerged as a priority for the refugees which included many dimensions related to the quality of their health and health needs. The results of Chapter 2 precipitated in using wellness as a holistic lens to view Syrian refugee’s health and health needs in Chapter 3. The results of Chapter 3 added a more holistic view of Syrian refugee health, while highlighting the need for improved research methods addressing wellness in Syrian refugees. Chapter 4 clarifies and defines wellness from the perspective of Syrian refugee women.

Advances in health care have resulted in an increase in life expectancy causing a rapid growth in the number of older adults at a global level. At the same time, socioeconomic development is transitioning family structures and social relationships. With reduced family engagement, many older adults are more at risk for physical and psychological health issues including loneliness, which is considered a public health issue affecting their quality of life and well-being. This descriptive, exploratory study aims to describe the significance of loneliness in three northern regions of the Sultanate of Oman. The purpose of this study is to examine the prevalence and correlates of loneliness and the relationship of loneliness to health statuses among older Omani adults aged 60 years and above. A demographic data questionnaire, the UCLA loneliness scale, and SF-12-v-1 health status instruments were used for data collection. The sample includes 113 Omani older adults, male (n = 36) and female (n = 77), who experienced a mixture from low to high and severe levels of loneliness. Among these older adults, 34.5% perceived low level, 34.5% moderate level, 22.1% high, and 8.8% were severely lonely. The main demographic factors that were associated with the older adults level of loneliness were female gender, older age 80 years and above, living with others who were not a family member, and being unemployed. When controlling for demographic and environmental factors loneliness was a significant predictor (p < .001) for lower mental health status but not for physical health status (p > .05).

Late preterm infants (LPIs), born between 34 and 37 weeks gestation, are at risk for a myriad of health conditions related to neuro-muscular and physiologic immaturity. However, relative stability allow many of these infants to avoid care in specialty nurseries and discharge home with their mothers after birth. Due to underlying immaturity, feeding difficulty is the most common issue LPIs experience, resulting in early breastfeeding cessation, increased risk for secondary diagnoses, and hospital readmission. The purpose of this study was to assess early breastfeeding behavior of LPIs, including testing inter-rater reliability of an assessment tool and the feeding patterns of infants over time. An extensive review of breastfeeding assessment tools resulted in the selection of the Premature Infant Breastfeeding Behavior Scale (PIBBS) based on its reliability and validity in the preterm infant population. A convenience sample of LPI dyads was recruited and used to conduct inter-rater reliability testing of PIBBS. A longitudinal one-group non-experimental study was used for observational follow-up. A strong statistical agreement of PIBBS scores occurred between mothers and a healthcare professional (Cohen’s kappa values of items ranged from .776 to 1.000, p = <.001). Participants continued using the PIBBS tool after hospital discharge until their infants expected due dates (40 weeks adjusted age). T-test analyses were conducted to examine changes in scores over time indicating increase in item scores (p = .003 - .193). PIBBS appears to be a valid and reliable tool to assess breastfeeding among LPI dyads. Incorporation of PIBBS into a comprehensive plan of care could better support and protect breastfeeding among the LPI population.

Cardiovascular disease (CVD) is the leading cause of mortality in the U.S. While physical activity can reduce CVD risk, most adults do not engage in adequate physical activity to maintain or improve health. Older adults are less likely to participate in physical activity and experience a greater burden of CVD compared to younger adults. Despite knowledge of motivators and barriers to physical activity, the challenge to reduce cardiovascular risk in the older adult population remains unmet. Older adults face unique and complex barriers to physical activity, including limited social contextual resources and behavioral change processes. Interventions to enhance wellness motivation have demonstrated potential in promoting health behavior change among older adults.

The purpose of this study was to examine the feasibility of the Yoga for HEART (Health Empowerment and Realizing Transformation) Intervention to increase motivation for physical activity and improve cardiovascular health in older adults. A pilot randomized controlled trial design was used. The Intervention group received Yoga for HEART, a 12-week program to foster motivation for health behavior change. The Control group received a 12-week group yoga program that did not contain theory-based components. The intervention was based on Wellness Motivation Theory, conceptualizing health behavior change as dynamic process of intention formation and goal-directed behavior leading to the development of new and positive health patterns. Critical inputs (i.e., empowering education, motivational support, social network support) were designed to promote social contextual resources and behavioral change processes to increase motivation for physical activity and improve cardiovascular health.

Specific Aims were to: (a) examine intervention acceptability, demand, and fidelity, and (b) evaluate intervention efficacy in promoting physical activity and improving cardiovascular health through increased social contextual resources and behavioral change processes. Participants in the Intervention group realized a significant reduction in body mass index (BMI) from baseline to 12 weeks when compared to participants in the Control group. Intervention group participants demonstrated improvement in theoretical mechanisms (i.e., self-knowledge, motivation appraisal, self-regulation, environmental resources) and intended outcomes (i.e., body composition) when compared to Control group participants. Findings from this study support the feasibility of the Yoga for HEART Intervention in older adults.

Sedentary behavior has recently been recognized as a widespread, independent risk factor for increased morbidity and mortality from chronic conditions including diabetes, cardiovascular disease, and cancer. Midlife women (age 40-64) are known to have high levels of sedentary behavior and corresponding cardiovascular disease risk. Currently, little is known about mechanisms involved in reducing and maintaining reductions to sedentary behavior in midlife women. Theory-based nursing interventions are needed which reflect process, personal meaning, person-environment interaction, and incorporate a strength-based perspective. Wellness Motivation Theory guided the research, conceptualizing behavioral change processes within culturally and environmentally relevant contexts, while recognizing bidirectional influences of personal and environmental factors on behavioral patterns. The Wellness Motivation Theory addresses social support and norms, community and material resources that influence behavioral choices, individual motivation and goals, and the behavioral change processes of self-knowledge, motivational appraisal, and self-regulation. A qualitative descriptive approach was used to explore social contextual resources and behavior change processes leading to action as decreasing sedentary time in midlife women. The maximum variation sample included 31 midlife women, employees of Arizona State University. Participants attended a one-hour focus group to discuss their experiences with sedentary behavior, and their efforts to sit less and move more. Midlife women characterized social support as: Raising Me Up, Timing Time and Walking and Talking. Support from contextual resources reflected themes of Seeking Place, Stepping Up, and Walking the Talk. Women experienced self-knowledge as Envisioning the Future, Taking Inventory, and Considering Possibles. Motivational appraisal was characterized as Reevaluating Priorities, Wayfinding, and Going All In. Self-regulation was reflected as Recounting Benefits, Keeping On Track, and Creating New Ways. A deeper understanding of motivational processes central to reducing sedentary behavior in midlife women fosters identification of leverage points for future theory-based intervention research which provides primary prevention opportunities to lower cardiovascular disease risk, and promote successful aging.

Nurses are ideally positioned to lead the transformation of healthcare delivery in the United States, however they must be prepared to do so. The Institute of Medicine has called for nurses to become change agents and assume leadership positions across all levels in order to become full partners with physicians and other health care providers. While clinical leadership is a responsibility for all nurses, expectations for new nurse clinical leadership have not been well studied.

This study sought to determine the nursing leadership competencies clinical managers expect of new nurses in an acute care setting and to identify gaps between end-of-program nursing leadership competencies, as outlined in The Essentials of Baccalaureate Education for Professional Nursing Practice, with leadership competencies identified by clinical managers in an acute-care setting.

A single, bounded case study approach was used to collect data from nurse managers and assistant nurse managers at one acute care hospital. Data from intensive interviews, focus groups, and archival records were analyzed. Seven major themes related to clinical leadership emerged, including intentional learning, communication, professional practice, advocacy, teamwork, influencing practice, and systems thinking. Traits, mentoring, and generational differences emerged as secondary themes.

Data from this study revealed a developmental sequence for clinical leadership. Certain expectations identified as antecedent to clinical leadership emerged initially, whereas other aspects of clinical leadership, developed later in the career trajectory. It was clear that accomplishing nursing care tasks was a fundamental expectation for professional nursing practice. Communication, teamwork and advocacy are crucial leadership competencies which help the new nurse to effectively manage time and provide safe, high-quality nursing care. As the new nurse continues to develop, systems thinking and influencing nursing practice emerge as significant expectations. Nurse managers have clear expectations for how new nurses should be prepared for clinical leadership. The degree to which clinical practice partners employing new nurses and academic nursing programs educating future nurses collaborate to establish expected outcomes is variable; however, academic-practice collaborations are crucial in developing educational standards for entry to practice in complex healthcare delivery systems.

Type 1 diabetes (T1D) is one of the most common chronic diseases in youth and it has been shown that adolescents have the worst glycemic control of any age group. The objective of this study was to develop, test and evaluate the feasibility of an online intervention (Can-Do-Tude) that uses the principles of motivational interviewing (MI) to deliver tailored diabetes self-management education to adolescents with T1D. Bandura’s efficacy belief system was used to guide the design of this study.



The study used a multi-phase, multi-method approach. The first phase (alpha) of this study was a qualitative descriptive design to examine the intervention’s fidelity. Evaluation of performance was conducted by experts in the fields of MI, T1D, adolescence and/or online education. The second phase (beta) was a quantitative descriptive design conducted in order to evaluate feasibility by examining the acceptability (recruitment, retention and satisfaction) and implementation (diabetes self-management self-efficacy) to determine whether the intervention was appropriate for further testing.

First phase findings showed that the intervention passed all measures with the content experts (n = 6): it was functional, accurate, usable and secure. Improvements to the intervention were made based on reviewer recommendations. For the second phase 5 adolescents between 14 and 17 were enrolled. Three adolescents completed all 4 weeks of the intervention while 2 completed only 3 weeks. Participants (n = 3) rated satisfaction on a 5-point Likert-type scale ranging from “not at all” satisfied (1) to “very much” satisfied (5). There was a positive response to the intervention (M = 4.28, SD = 0.55). Implementation was measured by a pre- and post-test for diabetes self-management self-efficacy. Participants (n = 3) demonstrated overall improvements in diabetes self-management self-efficacy (Z = -2.952, p = .007).

Implications for further Can-Do-Tude research are planned at a metropolitan diabetes center using updated technology including an application platform. Although the sample was small, findings indicate that the intervention can be conducted using a web-based format and there is initial evidence of improvement in self-efficacy for diabetes self-management.

Scientific evidence strongly indicates that there are significant health benefits of breastfeeding. Lower breastfeeding initiation, duration, and exclusivity rates are found in vulnerable populations particularly among women of low socioeconomic status, and racial minorities such as immigrant, racial, and minority cultural groups. Breastfeeding disparities can contribute to negative health outcomes for the mothers, and their infants, and families.

Muslim Arab immigrants are a fast-growing, under-studied, and underserved minority population in the United States. Little is known about breastfeeding practices and challenges facing this vulnerable population. Immigrant Muslim Arab mothers encounter breastfeeding challenges related to religion, language, different cultural beliefs, levels of acculturation, difficulties understanding health care information, and navigating the health care system.

A cross-sectional descriptive study was used to describe infant feeding practices, and identify contributors and barriers to adequate breastfeeding using the social ecological model of health promotion. A convenience sample of 116 immigrant Muslim Arab women with at least one child, 5 years or younger was recruited from a large metropolitan area in the Southwestern United States. The results indicated that immigrant Muslim Arab mothers demonstrate high breastfeeding initiation rates (99.2%), and lengthy breastfeeding duration (M=11.86), but low rates of exclusive breastfeeding at 6 months (21.6%). Facilitators to breastfeeding within the sample were high intentions to breastfeed, positive breastfeeding knowledge and beliefs related to the benefits of breastfeeding, religious teachings promoting breastfeeding, and encouragement to breastfeed from the mothers’ social support system. Several barriers to successful breastfeeding were related to lacking the specific knowledge of the benefits of breastfeeding, and discomfort with breastfeeding in public, and in front of strangers. High income and religious teachings encouraging breastfeeding were significantly associated with exclusive breastfeeding at six months. Greater maternal age and comfort with breastfeeding in public were associated with longer breastfeeding durations.

The socio-cultural context for support of breastfeeding is an important consideration by healthcare providers caring for Muslim Arab women. An ecological perspective needs to be applied to interventions targeting breastfeeding promotion to facilitate effectiveness in this population. Culturally tailored intervention to the specific breastfeeding concerns and needs of Muslim immigrant women could promote optimal breastfeeding in this population.

This cross-sectional descriptive study was designed to examine critical care registered nurses’ perceptions of nurse-to-nurse incivility and professional comportment, and the extent to which education, nurses’ age, nursing degree, and years of nursing experience is related to their perceptions on these topics. Professional comportment is comprised of nurses’ mutual respect, harmony in beliefs and actions, commitment, and collaboration. Yet, it was unknown whether a relationship existed between a civil or uncivil environment in the nursing profession and nurses’ professional comportment. Correlational analyses were conducted to explore the relationship between perceptions of nurse-nurse incivility and professional comportment, and the relationships between incivility and professional comportment education and perceptions of nurse-nurse incivility and professional comportment. Multiple linear regression analyses were conducted to identify predictors of perceptions of nurse-nurse incivility and professional comportment. Results indicated statistically significant relationships between perceptions of nurse-nurse incivility and professional comportment, and between professional comportment education and perceptions of professional comportment. Professional comportment education was identified as a statistically significant predictor of increased perceptions of professional comportment. Findings of the current study may assist in establishing more targeted and innovative educational interventions to prevent, or better address, nurse-nurse incivility. Future research should more clearly define professional comportment education, test educational interventions that promote professional comportment in nurses, and further validate the Nurse-Nurse Collaboration Scale as a measure of nurses' professional comportment.