Noscomial Urinary Tract Infection - Research Paper Example

 Noscomial Urinary Tract Infection ABSTRACT Catheter acquired urinary tract infection have remained a common and well-known healthcare related infection. The use of rubber indwelling catheter contributes 70-80% of nosocomial urinary tract infections. In the United States, a study by National Health care Safety Network (NHSN) identified that between 45-79% of adult patients in the medical and surgical wards have the indwelling catheter. This makes it a common observation that significantly increase the risk for nosocomial infections. Catheters remaining in situ for 30 days are considered indwelling. The danger of the situation is that with the repeated emptying of the urinary bag and handling of the catheters, there is risk of a rise of the infection causing microorganisms from the environments, beddings and contaminated hands of the patient or the caregiver (Temiz et al., 2012). Besides the indwelling catheter, however, nosocomial urinary tract infections can result from contaminated beddings that cause direct entry of microorganisms, and inappropriate insertion of contaminated hands as in vaginal examination (Nakamura & Tompkins, 2012). Nosocomial urinary tract infection has direct effects on the health of the patient as well as on the healthcare provision process. First, acquiring an infection during treatment is emotionally stressing to the patient. This is because an extended hospitalization time implies that the patient spends more time and money on medication and care. Secondly, the reputation of the hospital can be risked by cases of nosocomial infections (Hälleberg Nyman et al., 2011). This is because acquiring an infection in the course of treatment amounts to negligence and a breach of the code of ethics. The implication of this to the involved nurses can be sued for failure to ensure non-maleficence on the side of the patient. Besides, the extended hospitalization increases the risk for further infections and increased workload for the nurses and other healthcare professionals. Solving the problem has therefore become a serious focus in healthcare research and the search for answers. Different measures have been studies, among them are the reduction of catheterization time and the use of bladder scanner (Nakamura & Tompkins, 2012). Course Project: Part 1---Identifying a Researchable Problem Introduction As I dwell and ponder upon many topics of interest to me in the health care setting, one that stands out beyond most is nosocomial urinary tract infection. In the hospital setting, the reason for seeking treatment for every patient is recovery. This recovery is expected to be fostered by the professional collaboration of the healthcare partners in the hospital. However, sometimes in the process of provision of healthcare, more health problems arise. These problems are not present in the patient until after admission are termed nosocomial. Hospital infections are among the worst scenarios in any healthcare facility (Hälleberg Nyman, Johansson, Persson, & Gustafsson, 2011). This is because the reputation of any healthcare process depends on its ability to solve the presenting problem of the patient without affecting his or her health. Urinary tract infections are among the most common nosocomial infections. The condition is attributed to more than a third of all hospital acquired infections that result in extended hospitalization and readmission of patients (Nakamura & Tompkins, 2012). Regardless of the patient’s sex, urinary tract infection has become a challenge in health care owing to the increased need for extended admission with terminal illnesses and HIV/AIDS. The relationship between these and nosocomial urinary tract infection is that catheterization is a chief cause of infection. The purpose of this paper is to identify a researchable problem and formulate a question that targets the goal of my research. As known by many, the question is key beyond all other aspects of research. Research Questions A research into nosocomial urinary tract infections can prompt many questions. Feasibility encompasses several issues (Polit & Beck, 2012). This paper will focus on five important questions that are likely to be considered in data collection. These questions as generated for the sake of this paper are as follows: 1. What is the incidence of nosocomial urinary tract infections in American hospitals? 2. How has this incidence changed over the last five years? 3. What are the measures that hospitals take to curb the problem locally? 4. What are the direct effects of nosocomial urinary tract infections to the hospitals and staff? 5. What are the professional recommendations to decrease the problem? From the first question, the objective will be to assess the depth of the problem in the country. The data collected from both primary and secondary sources can be used to identify and quantify the problem. The second question is related to the first. In this case, the focus will be on identifying the trend of the problem in the recent past. This trend will clearly indicate the success of the measures that the hospitals, authorities and other concerned bodies have undertaken if any. The third question focuses on specific hospitals and managements and the measures that they have taken to identify and address the problem of nosocomial urinary tract infections (Davies, 2011). The fourth question focuses on the effects of the problem on the hospitals, the patients, and the staff. This question will be directed to the hospital management, the patients, and the staff and will seek to identify their perspective of the problem. The fifth question seeks to check on the recommendations that professional bodies have on reducing the problem from the hospitals. These questions will collectively paint a current and a clearer picture of the problem as it is and help in seeking a lasting solution to the issue. For this paper, my question focuses on two popular interventions towards reducing the problem of hospital-acquired urinary tract infections. The question is: In Progressive Care Unit patients (P) does the use of portable bladder scanner (I) reduce the risk of nosocomial urinary tract infections (O) compared to indwelling urinary catheterization (C) over length of hospital stay (T)? A PICOT question must address the population under focus (P) and the intended intervention to curb the problem (I). In addition, the question must seek to address the comparison between the outcomes of the intervention and an alternative of the same within a specified time frame. My question strategically covers all these parts. Keywords for Literature Search Various keywords can be used to conduct a literature search to assist in identifying evidence to answer the identified PICOT question. These keywords include as follows: inpatient, progressive care unit, portable bladder scanner, nosocomial urinary tract infections, indwelling catheterization, extended hospitalization, catheter acquired urinary tract infection, cross contamination, adult and decrease. I chose these keywords because they are all essential to my PICOT question and these keywords help give a better understanding to exactly what the question is asking. Part 2 Literature Review Introduction Presently, progressive care is becoming an increasing trend in hospitals across the United States. Progressive Care Units, commonly abbreviated as PCUs, are experiencing increased intensity in the number of patients’ admissions. In clinical contexts, PCUs are meant to provide care for patients who are medically stable, but whose medical conditions are at high risks of spontaneously evolving into life-threatening stages. Most of these PCU patients are just out of surgical units; hence they are practically not under critical care. Typically, patients placed under progressive care include those in need of intensive wound management especially after surgeries, and those recovering from cardiovascular complications and are in need of extensive pulmonary interventions. In practical contexts, one challenge faced by patients in progressive care is nosocomial infections (Davies, Louis & Smith, 2002). Nosocomial infections are hospital-acquired infections that primarily results from the synergistic effect of a patient’s compromised immune system during treatment, and treatment procedures that act as pre-disposing factors to specific infections. In contemporary healthcare settings, nosocomial urinary tract infection feature as a common example of hospital-acquired infections affecting patients placed under progressive care (Farrell, Morrissey & Robbins, 2013). Systematic Review Technically, relevant health statistics from previous research exercises indicate that nosocomial urinary tract infections account for approximately 42% of all nosocomial infections (Foxman, 2012). In addition, hospital-acquired urinary tract infections increase the direct cost of acute hospitalization care by $500-$1000 per patient. Besides the element of increased hospitalization costs, nosocomial urinary tract infections is known to considerably increase patients’ discomfort; hence compromising on the desired levels of patient satisfaction in progressive care units. In the light of these relevant health effects, healthcare institutions are enhancing their efforts of minimizing the occurrences of nosocomial infections, especially nosocomial urinary tract infections. One practical approach used in the mitigation of nosocomial UTIs is the curbing of risk and causative factors (Davies, Louis & Smith, 2002). Apparently, patients in PCUs have increased urinary frequencies and urinary incontinence; hence they require assisted urination techniques like indwelling urinary catheterization and use of portable bladder scanners in assessment of post void residual volume. Some of these assisted urination techniques act as risk factors for nosocomial urinary tract infections. Allegedly, use of indwelling urethral catheters increase the chances of acquiring urinary tract infections by approximately 5% each day, while the use of portable bladder scanners seems to reduce occurrence of the nosocomial infection. From a pathogenesis point of view, urinary tract infections are caused by presence of bacteria, specifically enteric bacteria along the urinary tract. In progressive care, use of indwelling urethral catheters provides a surface for adhesion of pathogenic bacteria that cause urinary tract infections. In essence, urinary catheterization involves invasive insertion of a flexible tube along a patient’s urethra in order to drain urine from a patient’s bladder (Stamm, 2011). During insertion and manipulation of the flexible urethral catheter tubes, pathogenic bacteria can gain entry into a patient’s urinary tract and into the bladder. Once inside the bladder, bacteria incubate and multiply, leading to contraction of urinary tract infections in a period of approximately 48 hours after insertion of indwelling urethral catheters. In this case, urinary catheterization provides a mechanism through which pathogenic bacteria is inoculated into patients’ urinary tracts. In addition, prolonged presence of urinary catheterization tubes inside patients’ urinary tracts provide suitable conditions for adhesion of bacteria to mucus membranes, and subsequent colonization of the urinary tracts by the inoculated bacteria, causing urinary tract infections (Foxman, 2012). Integrative Review As aforementioned, alternative methods for assisted urination, especially the use of portable bladder scanners seems to reduce risks associated with acquisition of nosocomial urinary tract infections among patients in PCUs. In one study conducted by the school of health sciences at the University of Chicago, findings indicated that ultrasound scanning in evaluation of patient’s residual urine reduce urinary tract disturbance and occurrence of urinary tract infections by 56% compared to the use of indwelling urinary catheterization during hospital stay periods. The study conducted in April 2014 sampled 30 patients placed under progressive care units for periods exceeding 30 days at the Chicago’s Northwestern Memorial Hospital (Haines, 2014). According to the study, urinary catheterization is a more accurate method for the determination of residual urine compared to the use of portable ultrasound bladder scanners. Despite possessing the attribute of increased accuracy, urinary catheterization is not only embarrassing and discomforting to patients, but also present increased chances of introducing pathogenic microorganisms into patients’ urinary tracts. Contrarily, use of ultrasound bladder scanners is a non-invasive procedure with no chances of introducing bacteria into patients’ urinary tracts (Haines, 2014). Contradictions and Possible Explanations Despite the proposition that the use of portable bladder scanners offers fewer chances of UTI contraction compared to urinary catheterization, the latter is still referred to as the gold standard for detection of post void residual volume. Based on the analyzed research articles, contradictions exist as to whether urinary catheterization methods actually increase occurrence of nosocomial UTIs in progressive care patients, and whether the use of portable bladder scanners is the best remedy for nosocomial UTIs. The first inconsistency in contradictory research findings is the fact that even patients placed under ultrasound bladder scanning in detection of residual urine still contract nosocomial urinary tract infections (Stamm, 2011). Apparently, other secondary factors that cause urinary tract infections include congenital urinary tract abnormalities, nutrition, and lack of circumcision among male patients. In progressive care units, the chances of acquiring UTIs from these secondary factors increase, especially because patients in PCUs have weak immune systems. Another inconsistency in the causes of nosocomial urinary tract infections pertains to the level of antisepsis in clinical environments. Most progressive care units in healthcare institutions are either understaffed or lack the appropriate methods and technologies for optimal sterilization of indwelling urethral catheters. Apparently, sterilization of urethral catheters using cutaneous antiseptic agents like 3% aqueous chlorhexidine reduces the risk of urinary catheterization-related UTIs by up to 45% (Farrell, Morrissey & Robbins, 2013). Preliminary Conclusion Despite the elaborated inconsistencies and contradictions, the invasive nature of urinary catheterization still feature as the main risk factor of nosocomial UTIs, while the noninvasive nature of ultrasound bladder scanners feature as an attribute that reduce the risk of hospital-acquired urinary tract infections. Existing research on nosocomial urinary tract infections provides sufficient evidence regarding the causative nature of indwelling urinary catheterization. Admittedly, the only cause of urinary tract infections is the presence of pathogenic bacteria inside a patient’s urinary tract (Davies, Louis & Smith, 2002). In this case, any invasive clinical technique that invariably increases the chances of introducing bacteria into a patient’s urinary tract qualifies as a candidate for increasing the risk of nosocomial UTIs. On the other hand, any noninvasive clinical method that prevents inoculation of bacteria into a patient’s urinary tract qualifies as a candidate for reducing the risk of nosocomial UTIs. Despite presence of contradictions regarding secondary causes of UTIs and antisepsis in the use of urethral catheters, existing literature ascertains that portable bladder scanners reduce the risk of hospital-acquired urinary tract infections, while the use of indwelling urethral catheters increases the risk of nosocomial urinary tract infections for lengthy hospital stays. Conclusion The studies that I found throughout my research for my PICOT question reveals that the current state of knowledge is extensive. There are many studies with knowledge on this question and there were some inconsistencies and contradictions but overall the studies were well done. The evidence provided from these studies provides strong support for a change in practice and there is ample research that adequately addresses my inquiry. Part 3: Weighing the evidence While doing my research, I identified much valuable information on my PICOT question. The information given is much valuable. After an examination of the information, I got many indications in nursing practices. In this part of my research, I will conduct the translation of the data and evidence from literature review into those authentic practices adopted for the improvement of the outcomes of health care (Dingle, 2011). I will also put into consideration the strategies and possible methods for evidence-based practice dissemination to colleagues and the broader field of health care. Picot question Restating PICOT question: In Progressive Care Unit patients (P) does the use of portable bladder scanner (I) reduce the risk of Nosocomial urinary tract infections (O) compared to indwelling urinary catheterization (C) over length of hospital stay (T)? P – Population/Problem: Progressive Care Unit patients I – Intervention: Portable bladder scanner C – Comparison: Indwelling urinary catheterization O – Outcome: Reduced hospital-acquired urinary tract infections Summary of findings Catheter acquired urinary tract infection, have remained a common and well-known healthcare related infection. The use of rubber indwelling catheter contributes 70-80% of nosocomial urinary tract infections. In the United States, a study by National Health care Safety Network (NHSN) identified that between 45-79% of adult patients in the medical and surgical wards have the indwelling catheter. This makes it a common observation that significantly increases the risk for Nosocomial infections. Catheters that remain in situ for more than 30 days are considered indwelling (Katapodi & Northhouse, 2011). The danger of the situation is that, with the repeated emptying of the urinary bag and handling of the catheters, there is risk of anincreased infection causing microorganisms from the environments, beddings, and contaminated hands of the patient or the caregiver (Temiz et al., 2012). Besides the indwelling catheter,Nosocomial urinary tract infections can result from contaminated beddings that cause direct entry of microorganisms, and inappropriate insertion of contaminated hands as in vaginal examination (Nakamura & Tompkins, 2012). As aforementioned, alternative methods for assisted urination, especially the use of portable bladder scanners seems to reduce risks associated with acquisition of nosocomial urinary tract infections among patients in PCUs. In one study conducted by the school of health sciences at the University of Chicago, findings indicated that ultrasound scanning in evaluation of patient’s residual urine reduce urinary tract disturbance and occurrence of urinary tract infections by 56% compared to the use of indwelling urinary catheterization during hospital stay periods. The study conducted in April 2014 sampled 30 patients placed under progressive care units for periods exceeding 30 days at the Chicago’s Northwestern Memorial Hospital (Haines, 2014). According to the study, urinary catheterization is a more accurate method in the determination of residual urine compared to the use of portable ultrasound bladder scanners. Despite possessing the attribute of increased accuracy, urinary catheterization is not only embarrassing and discomforting to patients, but also present increased chances of introducing pathogenic microorganisms into patients’ urinary tracts. Contrarily, use of ultrasound bladder scanners is a non invasive procedure with no chances of introducing bacteria into patients’ urinary tracts (Haines, 2014). Outcomes Solving the problem of hospital-acquired infections has, therefore, become a serious focus in healthcare research and the search for answers. Different measures have been applied towards solving this problem; one nursing practice that I’ve identified is the reduction of catheterization time and the use of bladder scanner in preference to indwelling catheters. There is need apply the nursing practice mentioned since Nosocomial urinary tract infection has direct effects on the health of the patient as well as on the healthcare provision process (Dingle, 2011). First, acquiring an infection during treatment is emotionally stressing to the patient. This is because an extended hospitalization time implies that the patient spends more time and money on medication and care. Secondly, the reputation of the hospital can be risked by cases of Nosocomial infections (Halleberg Nyman et al., 2011). This is because acquiring an infection in the course of treatment amounts to negligence and a breach of the code of ethics. The implication of this to the involved nurses can be sued for failure to ensure non-maleficence on the side of the patient. Besides, the extended hospitalization increases the risk for further infections and increased workload for the nurses and other healthcare professionals (Nakamura & Tompkins, 2012). Strategies I plan to get the message of high chances for reduced contraction of Nosocomial urinary tract infections across by communicating the need to use portable bladder scanners as opposed to indwelling catheters. According to existing evidence, it is proposed that the use of portable bladder scanners offer fewer chances of UTI contraction compared to urinary catheterization, however, the latter is still referred to as the gold standard for detection of post void residual volume (Bernd, Prel & Blettner, 2009). Based on the analyzed research articles, contradictions exist as to whether urinary catheterization methods actually increase occurrence of nosocomial UTIs in progressive care patients, and whether the use of portable bladder scanners is the best remedy for nosocomial UTIs (Fifi & Nadia, 2012). The first inconsistency in contradictory research findings is the fact that even patients placed under ultrasound bladder scanning in detection of residual urine still contract nosocomial urinary tract infections (Stamm, 2011). Apparently, other secondary factors that cause urinary tract infections include congenital urinary tract abnormalities, nutrition, and lack of circumcision among male patients. In progressive care units, the chances of acquiring UTIs from these secondary factors increase, especially because patients in PCUs have weak immune systems (Stichler, 2010). Another inconsistency in the causes of Nosocomial urinary tract infections pertains to the level of antisepsis in clinical environments. Most progressive care units in healthcare institutions are either understaffed, or lack the appropriate methods and technologies for optimal sterilization of indwelling urethral catheters. Apparently, sterilization of urethral catheters using cutaneous antiseptic agents like 3% aqueous chlorhexidine reduces the risk of urinary catheterization-related UTIs by up to 45% (Farrell, Morrissey & Robbins, 2013). Summary of Project This project was enlightening. I admit it was challenging in its beginning but after finishing, I have realized that it has helped me view research in a different direction. Before conducting this project, it was almost impossible for me to identify a research problem. As a result of exposure to research problem identification process and the PICOT model, I now have a future reference. Through the project, I’ve also learnt to conduct a literature review. Though it is time consuming and in-depth, literature review is essential as part of the process. A good literature review gives evidence-based research and enables the translation of evidence to be easier. Furthermore, through the project, I have learnt on how to weigh existing evidence to the identified problem. References Bernd, R., du Prel,J.B., & Blettner, M. (2009). Study design in medical research: Part 2 of a series on the evaluation of scientific publications.DeutschesAerzteblattInternational,106(11),184-189.Retrievedfrom http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695375/pdf/Dtsch_Arztebl_Int-106-0184.pdf Davies, D. H., Louis, J., & Smith, A. (2002). Incidence and risk factors for acquiring nosocomial urinary tract infection in the progressive care units. Journal of Critical Care, 17(1), 50-57. Dingle, P. (2011) Statin statistics: Lies and deception. Positive Health, 180, 1.Retrieved from: doi http://academicguides.waldenu.edu/nurs6052. Farrell, D., Morrissey, I., & Robbins, M. (2013). A UK multicenter study of the antimicrobial susceptibility of bacterial pathogens causing urinary tract infections. British Medical Journal, 45(7), 62-75. Fifi R. & Nadia A. (2012).Nosocomial infection of Urinary tract endoscopies: Incidence and prevention of nosocomial infection of urinary tract endoscopies by different antimicrobial agent. Saarbrücken: LAP LAMBERT Academic Publishing. Foxman, B. (2012). Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. The American Journal of Medicine, 99(3), 84-91. Haines, K. (2014). Reducing catheter-associated urinary tract infection through bladder ultrasound. International Journal of Surgical Care and Patient Safety Improvement, 14(6), 177-183. Katapodi, M.C. & Northhouse, L.L.(2011). Comparative effectiveness research: Using systemic reviews and meta-analysis to synthesize empirical evidence. Research & Theory for Nursing Practice, 25(3), 191-209. doi: http://www.ncbi.nlm.nih.gov/pubmed/22216693. Stamm, W. E. (2011). Catheter-associated urinary tract infections: Epidemiology, pathogenesis, and prevention. The American Journal of Medicine 107(4), 65-71. Doi: http://www.cdc.gov/hicpac/SSI/ref-SSI.html Stichler, J.F. (2010). Evaluating the evidence in evidence-based design. Journal of Nursing Administration, 40(9), 348-351. doi http://academicguides.waldenu.edu/nurs6052. Part 3 Weighing the Evidence While conducting my research, I found plenty of valuable information on my PICO question. The information provided is very valuable. After examining this information, I found several indications that it has in nursing practices. In this portion of my research I will translate the evidence and data from my literature review into authentic practices that can be adopted to improve health care outcomes. I will also consider possible methods and strategies for disseminating evidence-based practices to my colleagues and to the broader health care field. PICO Question Restating PICO question: Do children of different ethnic background and different socioeconomic status have the same opportunities to live healthy lifestyles and decrease childhood obesity? P – Population/Problem: Children, School Aged, Obesity I – Intervention: Healthy Lifestyles C – Comparison: Unhealthy Lifestyles O – Outcome: Decrease Childhood Obesity My PICO question is significant to nursing practice because childhood obesity is getting out of hand and we, as healthcare professionals, have to help get it turned in a positive direction. We can do so by continuing to educate and show how important it is to live a healthy lifestyle. And it is also important, when educating, to show how obesity can lead to other healthcare problems down the road. Summary of Findings The findings from the articles that I selected for my literature review all show that socioeconomic status does have an impact on childhood obesity. One nursing practice that is supported by the evidence in the articles is teaching about healthy lifestyles. The research showed differences across races and the research also showed that these socioeconomic inequalities could lead to other healthcare diseases in adulthood. Haas states, “Blacks had the highest rate of poverty, whereas Whites had the lowest” (Haas, 2003, p 2106). The research also shows that other factors contribute to obesity as well such as lifestyle, acculturation, and cultural beliefs and practices. The fact that Blacks had the highest rate of poverty/worst socioeconomic status and high rate of childhood obesity shows that if we can decrease these socioeconomic inequalities we can decrease the childhood obesity rate. If people in areas of low socioeconomic areas had access to healthier choices they would likely make healthier decisions. For example, if they had access to healthier foods, fresh fruits and vegetables, etc they would be able to eat healthier. If the children had access to a safe playground, they would be able to exercise and have fun at the same time. Healthier lifestyles will help decrease the rate of childhood obesity and in the long run help prevent other health related problems. Howe states, “The fact that we observe the emergence of socioeconomic inequalities in adiposity in children as young as 4 years old, and the fact that these inequalities are widening with increasing age of the children suggests that these children may well demonstrate even wider socioeconomic inequalities in adulthood obesity, cardiovascular diseases, and diabetes than those experienced by contemporary adults” (Howe, 2011, p 151). Education is the key to helping decrease childhood obesity. Outcomes The evidence-based practice that I identified contributes to better outcomes because when people understand just how important it is to live a healthy lifestyle they will make better choices and have more positive outcomes as it relates to their health. Once more and more people have the knowledge, it will lead to results. But we have to find a way to decrease the socioeconomic disparities in order for some to have the opportunity to make better choices. Because for some people, they want to live healthier lifestyles but don’t have the opportunity to do so. The negative outcomes that could result from failing to use the evidence-based practice is that the childhood obesity rate could continue to increase. And with an increasing rate of childhood obesity will come an increase in many other health problems as adults. Strategy I plan on getting the message out by showing and not telling. What I mean by that is I will have actual people come in and give their testimony. Some of the people that come in to speak will be people that turned their life around and began to live healthier lifestyles and some will be those that have not been living a healthy lifestyle. That way people will be able to have a better understanding of the importance of living a healthy lifestyle. I would not have to communicate the importance of living a healthy lifestyle once my colleagues had seen some of the unhealthy cases for themselves. Once my colleagues have seen these cases I don’t think I would have a problem getting a protocol implemented for educating on healthy lifestyles and hopefully getting a program together for those that need help getting what they need to live a healthier lifestyle. I would address concerns by having meetings every so often. The place, time, a structure of the meeting would be adjusted to fit whatever is best for the community. Summary of Project This project was very enlightening. I admit it was very challenging in the beginning but I feel as though it has helped me to look at research in a completely different way. Before doing this project I would never have known how to identify a researchable problem. Being exposed to the process of identifying a researchable problem and the PICO model will prove to be valuable for future reference. I am no expert but doing this project gives me a better understand of how to go about doing a literature review. It is a very in depth process and is very time consuming but the literature review is a very important part of the process. If you do a project without a thorough literature review your project may be based off of poor information. So it is important to have a good, thorough literature review to make sure the literature you are using is indeed evidence-based research. Once a good literature review has been conducted it will make translating evidence into practice somewhat easier. References Austin, A. (2007). The Journal of Chi Eta Phi Sorority. The Correlation Between Socioeconomic Status and Obesity in Minority Children. Vol 52, (1), p 9-16. Chapman, B.P., Fiscella, K., Duberstein, P., Coletta, M., & Kawachi, I. (2009). Health Psychology. Can The Influence of Childhood Socioeconomic Status on Men’s and Women’s Adult Body Mass Be Explained by Adult Socioeconomic Status or Personality? Vol 28, (4), p 419-427. Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75–80. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144 Haas, J.S., Lee, L.B., Kaplan, C.P., Sonneborn, D., Phillips, K.A., Liang, S. (2003). American Journal of Public Health. The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents. Vol 93, (12), p 2105-2110. Howe, L.D., Tilling, K., Galobardes, B., Smith, G.D., Ness, A.R., & Lawlor, D.A. (2011). International Journal of Pediatric Obesity. Socioeconomic Disparities in Trajectories of Adiposity Across Childhood. Vol 6, p 144-153. Polit, D. & Beck, C (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edition, p 75-78. Waters, E., Ashbolt, R., Gibbs, L., Booth, M., Magarey, A., Gold, L., Kai Lo, S., Gibbons, K., Green, J., O’Connor, T., Garrard, J., & Swinburn, B. (2008). International Journal of Pediatric Obesity. Double Disadvantage: The Influence of Ethnicity Over Socioeconomic Position on Childhood Overweight and Obesity. Vol 3, p 196-204. Read More