The following are the currently funded research projects underway at Carolina Nursing to advance health care and improve lives.

Principal Investigator: Ruth A. Anderson, PhD, RN, FAAN

Funded by: National Institutes of Nursing Research via Duke University subcontract (2015-17)

Abstract: Although efficacy trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents, attempts to translate those interventions into practice using current standard of care quality improvement (QI) techniques have not been successful. Using a complexity science framework, our previous RO1 has shown that low connection, information flow, and cognitive diversity among NH staff explains much of the poor quality of care delivered for complex problems such as falls. Our pilot test of “CONNECT”, a multi-component intervention that encourages staff use simple strategies to make new connections with others, enhance information flow, and use cognitive diversity, demonstrated that staff can learn to improve the density and quality of their interactions, and that this change in behavior is associated with a trend to lower fall rates. We hypothesize that higher levels of connection, information flow and cognitive diversity fostered in the CONNECT Intervention are necessary before any QI intervention for a complex geriatric problem such as falls can be successful.

This 5-year study will use a prospective, cluster-randomized, outcome assessment blinded design, with NHs (n=16) randomized to either CONNECT and a standard falls QI program (CONNECT + FALLS) or FALLS alone. We estimate that 800 residents and 576 staff members will participate. Specific aims are to, in nursing homes: 1) Compare the impact of the CONNECT intervention plus a falls reduction QI intervention (CONNECT+FALLS) to a falls reduction QI intervention (FALLS) on fall risk reduction indicators (orthostatic blood pressure, sensory impairment, footwear appropriateness, gait; assistive device; toileting needs, environment, and psychotropic medication); 2) Compare the impact of CONNECT+FALLS to FALLS alone on fall rates and injurious falls, and determine whether these are mediated by the change in fall risk reduction indicators; 3) Compare the impact of CONNECT+FALLS to FALLS alone on complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality) and determine whether these mediate the impact on fall risk reduction indicators and fall rates and injurious falls. Cross-sectional observations of complexity science measures are taken at baseline, at 3 months, at 6 months, and at 9 months. Resident fall risk reduction indicators, fall rates, and injurious falls are measured for the 6 months prior to the first intervention and the 6 months after the final intervention is completed. Fall risk reduction indicators are the primary outcome. Secondary outcome measures include fall rates, injurious falls, and complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality). Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within nursing homes, and to control for covariates associated with fall risk, including baseline facility fall rates and staff turnover rates.

Principal Investigator: Linda Beeber, PhD, RN, FAAN

Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development (2016-2018)

Co-Investigators: George Knafl and Julee Waldrop, School of Nursing and Dore LaForett, Frank Porter Graham Child Development Institute

Abstract: This two-phase project will test the feasibility of integrating into Early Intervention (EI) services an intervention to enhance communication between infants and toddlers with diagnosed or suspected developmental disabilities and their depressed mothers. Federally-funded EI services are provided in all 50 states to infants and toddlers with developmental delays to improve long-term child cognitive and behavioral outcomes. EI services are optimized when the child receives consistent developmentally supportive activities as part of the family’s normal routines throughout the day, every day. EI services frequently include parent-implemented language enrichment interventions to increase child-centered speech and reciprocal (turn-taking) communication, which have been linked to positive child outcomes. Such interventions are dependent on consistent parent attentiveness, reciprocal interactions, and sensitivity to child cues. Depressive symptoms, prevalent in mothers of EI-enrolled children, can rob mothers of these capabilities. Fortunately, providing depressed mothers with concrete, attainable skills for improving interactions with their child can reduce the impact of depression on mother and child. EI is an ideal setting in which to integrate screening, support, and targeted communication skills for depressed mothers in order to improve EI child outcomes. First, we will use focus group and interview data to tailor a toolkit and training program for EI staff and determine whether it is feasible for staff to identify, screen and support mothers with depressive symptoms. Data on the toolkit will be collected from 4 EI staff on feasibility (ease of use, time required) and acceptability to mothers. Then, we will determine whether it is feasible for mothers to engage in an intervention to increase their child-centered speech and reciprocal communication using a technology-supported Language ENhancement Assessment/intervention system (LENA) embedded in EI services. The LENA uses an infant or toddler garment with an integrated audiotape device that records adult speech centered on the child, child vocalizations, and reciprocal turn-taking conversations between parent and child. The LENA software produces visual feedback that a mother can use to focus her language-based interactions with her child. The LENA-supported communication feedback intervention will be implemented with 10 mothers and 10 EI staff by using LENA one day a week for 16 consecutive hours for three consecutive weeks. Feasibility data, LENA communication data (adult word count, child vocalizations and conversational turn-taking), the Communication and Symbolic Behavior Scale, maternal depressive symptoms (PHQ-9) and child disability profiles (Mullen Scales of Early Learning) will be analyzed to determine the potential usefulness of the approach. The tailored intervention package will be designed for maximum scalability, with the ultimate goal of use by EI professionals across the country to enhance mother-child communication and maximize EI outcomes for children.

Principal Investigator: Kim Boggess, School of Medicine, Obstetrics and Gynecology (Lead) and Diane Berry, School of Nursing

Funded by: NIH Eunice Kennedy Shriver National Institute of Child Health and Human Development (2016-2021)

Co-Investigators: Laura Young, School of Medicine, Endocrinology

Abstract: Over 100,000 pregnant women with overt type 2 diabetes (T2DM) give birth in the United States every year. Strict maternal glycemic control is the key to optimizing infant outcomes. Medical treatment of overt T2DM in pregnancy is generally restricted to insulin as data on the safety and efficacy of oral hypoglycemic agents for overt T2DM is limited. However, over one-third infants born to women with overt T2DM experience an adverse outcome such as premature delivery, large-for-gestational age (LGA), hypoglycemia, hyperbilirubinemia, or birth trauma, suggesting that current treatment regimens fall short of optimizing outcomes. We believe that further research is needed to identify better strategies to reduce neonatal complications of overt T2DM in pregnancy. Metformin is the pharmacologic treatment of choice for overt T2DM outside of pregnancy. Metformin is favored over insulin because it results in less weight gain, fewer hypoglycemic episodes, and is oral rather than injectable. Metformin’s mechanism of action directly counteracts the insulin resistance characteristic of T2DM. Metformin is not recommended for treatment of T2DM complicating pregnancy, mainly because there are no large clinical studies examining its use in this context. Research is needed to address this knowledge gap. Our long-range goal is to optimize maternal and infant outcomes in overt T2DM complicating pregnancy. The objective of this proposal is to study the efficacy and safety of adjuvant metformin for treatment of T2DM among pregnant women receiving insulin therapy. Our central hypothesis is that compared to insulin alone, insulin plus metformin will result in improved neonatal outcomes. We will test this hypothesis by prospectively randomizing 1334 pregnant women with overt T2DM to insulin plus placebo therapy versus insulin plus metformin to accomplish the following specific aims: 1: To measure the effect of insulin/metformin on composite adverse neonatal outcome (perinatal mortality-miscarriage; stillbirth or neonatal death; preterm delivery, neonatal hypoglycemia, hyperbilirubinemia, and/or birth trauma); infant birth weight and fat mass, among pregnant women with T2DM.; 2: To measure safety of insulin/metformin use among pregnant women with overt T2DM; and 3: To quantify gestational weight gain (GWG) and satisfaction with therapy among women treated with metformin. Successful completion of this proposal will result in high quality contemporary evidence for management of overt T2DM complicating pregnancy to improve neonatal outcomes.

Principal InvestigatorJada Brooks, PhD, MSPH, RN

Funded by: NIEHS (2016-2018)

Mentors: David Peden, Pediatrics and Barbara Fredrickson, Psychology and Neuroscience

Scientific Advisors: Linda Beeber, School of Nursing and Giselle Corbie-Smith, Social Medicine

Biostatistician: Josephine Asafu-Adjei

Abstract: American Indian women experience particularly high mortality and morbidity from cardiovascular disease (CVD). Reducing this burden requires addressing preventable factors in the physical and psychosocial environment that are known to be important for the inflammatory responses involved in CVD. However, there is little evidence about the roles of environmental pollutant exposures and psychosocial factors in shaping immunologic function in American Indian women. This Mentored Patient-Oriented Research Career Development (K23) Award, entitled Inflammatory Markers, Hazardous Air Pollutants, and Psychosocial Factors proposes to address inflammation as a potential biological pathway linking environmental pollutant exposure and psychosocial factors to CVD in American Indian women. The working hypothesis is that American Indian women with positive psychosocial states are less susceptible to the inflammatory effects of environmental pollutants. The study will examine a sample of American Indian women (N = 150) drawn from southeastern North Carolina. A variety of assessment methods will be used, including survey methods, exposure assessment, and serum biomarker. Three Specific aims are to: 1) examine the association between environmental pollutants and inflammation in American Indian women; 2) examine the association between psychosocial states and inflammation in American Indian women; and 3) determine whether psychosocial states moderate the association between environmental pollutants and inflammation in American Indian women. With a background in nursing and epidemiology I am focusing my research on using community-based approaches to investigate relationships among environmental pollutants, psychosocial states, biological outcomes, and health disparities, particularly among American Indian women. The proposed training activities will include formal didactics and hands-on instruction in measurement and interpretation of environmental data, positive psychosocial states, and serum bioscience methods; community-engagement methods; responsible conduct in research; and attendance at national conferences. I have assembled an interdisciplinary mentoring team of internationally recognized experts who will provide me guidance in building new skills in environmental epidemiological measurement, psychosocial research, and serum biomarker measurement and analysis. The K23 award will move me to independence as a researcher, support my steps in securing funding as an independent investigator, and help me to become a nurse leader in environmental health disparities.

Principal Investigator: Jada Brooks, PhD, MSPH, RN

Funded by: National Institute on Drug Abuse via Florida Atlantic University Subcontract (2014-2019)

Co-Investigators: None

Abstract: Not available

Principal Investigator: Ashley Leak Bryant, PhD, RN, OCN

Funded by: National Cancer Institute via UNC Oncology Translational Award (2014-2017)

Mentors: Bryce Reeve, Hyman Muss, and Ethan Basch

Abstract: Not available

Principal Investigator: Cheryl Giscombe, PhD, RN, PMHNP-BC, FAAN

Funded by: Josiah Macy, Jr. Foundation


Abstract: The purpose of this project is to develop an interprofessional, academic-community partnership model to enrich provision of culturally-relevant, value-based mental health care for underserved populations. This model will be facilitated primarily via a partnership between faculty, student trainees, and a community health center. In addition, this model includes a curriculum that meets the Triple Aim objectives (safety, improved outcomes, cost-effectiveness) and prepares students and faculty to collaborate for care that is: (1) Value-based, including curricula on health economics and population management; (2) Culturally sensitive; (3) Contextually relevant, including curricula on social determinants of health; (4) Team-oriented; (5) Evidence-based; (6) Holistic regarding patient-centeredness and care coordination; and (7) Health policy-focused. This project will incorporate evidence-based frameworks for clinical and transdisciplinary education.  The method of teaching will follow the frameworks of deliberative practice and self-regulated learning, in the context of a supportive transdisciplinary environment that prioritizes holistic, patient-oriented care.

The short-term goals is to respond to calls for more academic-community partnerships for developing patient-centered, outcomes-oriented initiatives that are sustainable and scalable. The long-term goal is to create a model that can be replicated, disseminated, and applied by other academic-community partners. This model may provide a strategy for solving the shortage of community health center clinical training grounds; the shortage of clinical sites limits the enrollment of pre-professional students in mental health programs. In addition, this model can dispel negative perceptions about socioeconomically disadvantaged patients by exposing pre-professionals to the root causes of social disadvantage and suggesting strategies for team-oriented interprofessional clinical training with adequate resources and care coordination.  Ultimately, this model can facilitate better patient-provider relationships and sustainable outcomes that improve health of patients and their families. This project has the potential to reduce disparities in health care and outcomes by supporting the next generation of health professionals as they serve this community directly and develop strategies to improve care.

Principal Investigator: Donna S. Havens, PhD, RN, FAAN

Funded by: Department of Health and Human Services, Bureau of Health Professions (2014-2017)

Evaluator: Jennifer Leeman,  School of Nursing

Diversity Expert: Rumay Alexander,  School of Nursing

Faculty: Carol Durham, Gwen Sherwood, Debbie Travers, Hugh Waters, and Meg Zomorodi, School of Nursing

Physician Partner: Barry Saunders, Social Medicine

Abstract: Interdisciplinary collaborative practice (IPCP) is linked with positive outcomes for A NEPQR NCC Abbrtact the patient experience, population health and costs; however, little is known about how to make it happen and how to make it stick.  We are using four practice loca-tions: Emergency Departments (EDs) in 4 rural North Carolina hospitals (Chatham Hospital, Margaret Pardee  Memorial Hospital, Southeastern Regional Medical Center and Transylvania Hospital) We are implementing a 4 hospital learning collaborative to promote nursing’s capacity to lead development of and the competency to practice in IPCP environments in the ED – a set-ting “in crisis” and “at the breaking point” due to fragmentation of care — leading to delays, er-rors, and staff shortages (IOM, 2006). More notably, EDs are where in many rural areas, vulner-able populations go for all their care. Simultaneously implementing and evaluating the model in 4 diverse sites will enable rich comparisons of adaptation and implementation, which will inform replication. Nurse-led teams including patients/families will learn “about, from, and with each other” to collaboratively design care that will improve patient/family and clinician outcomes. Nurse leaders, emerging nurse leaders and nursing students will be integrated into project activi-ties to prepare a collaborative practice-ready nurse workforce. Goal: To promote nursing’s ca-pacity to lead development of and practice in IPCP environments to improve patient and clini-cian outcomes. Objectives: (1) To enhance nursing leadership to promote interprofessional communication and shared decision making; (2) To improve interprofessional relationships so they are characterized by mutual respect, shared goals and shared knowledge; and (3) To improve relational coordination (RC), leading to IPCP, with improved ED patient experience, improved ED population health, decreased ED costs and improved interprofessional outcomes. In-novation: The project will be guided by Positive Organizational Scholarship frameworks such as Relational Coordination (RC) and Appreciative Inquiry (AI). Interactive activities (e.g., simula-tion) will be used to build IPCP competencies and environments. Patient/family co-design of re-lational, structural, and work process features of the IPCP environment will give them “voice” to collaborate with health professionals to create the “excellent ED patient experience”. Because the ED is a microcosm of the hospital, situating the project in the ED provides great reach, enhancing potential for project spread to multiple areas, professionals, and services, promoting replication. Team Structure: NEPQR-IPCP teams consist of nurses, physicians, other professionals, units, departments and roles that each team feels are most important to coordinate quality ED care in their setting (local context). The UNC team offers expertise in nursing, medicine, implementation science, simulation education, teamwork, collaboration, safety and reflection, evaluation, cultural awareness, ED clinical/ operational research, statistics, RC Theory, and AI practice. Demographics of the patient population: The target population is all patients and families using services in 4 rural hospital EDs. The residents in the counties served by the 4 EDs include 339,974 rural residents, 272,998 residents in HPSAs and 307,784 residents in MUAs.

Principal InvestigatorEric Hodges, PhD, FNP-BC

Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development (2016-2018)

Co-Investigators: Cathi Proper, UNC Center for Developmental Science; and Todd Schwartz, UNC School of Nursing

Abstract: Once obese as an infant, the relative risk of remaining obese appears to rise with increasing age. Thus, the early years of life have been posited as an important target period for obesity prevention. Widely viewed as a response to genetic, interpersonal, and environmental factors, obesity fundamentally reflects an imbalance between energy intake and expenditure. Self-regulation of energy intake aligned with physiologic need is essential to this balance. The process(es) by which infants begin to disassociate eating behavior from physiologic need is unclear, thus it is crucial to better understand predictors of individual differences in self-regulation of energy intake. It is well established that autonomic regulation may support infant behavioral regulation, suggesting that autonomic function may be a critical area to consider here. Moreover, self-regulation is strongly influenced by dyadic interaction quality during infancy, and findings reveal that more responsive interactions are associated with more effective autonomic regulation. A chronic mismatch between a caregiver’s feeding behavior and the infant’s state (feeding in the absence of hunger and/or feeding beyond fullness), is thought to contribute to obesity by undermining the infant’s capacity to self-regulate intake; the current proposal will be the first to examine the effects on autonomic regulation.

We propose an intervention to enrich the capacity of mother-infant dyads to perform their respective interactive tasks. We plan to teach mothers American Sign Language (ASL) signs indicative of hunger, thirst, and satiety, which they will in turn teach their preverbal infant. This training in ASL will be augmented with targeted information for mothers about infants’ capacities to self-regulate energy intake in response to hunger and satiety and communicate those states with intention.  Mothers also will be taught about expected development of infants’ eating behaviors and nutritional requirements to support healthy growth.

Using a two-group randomized repeated measures design, this study aims to 1) evaluate the feasibility and acceptability of the intervention and study methods, including recruitment, enrollment, and data collection (self-report, anthropometrics, video observations, and respiratory sinus arrhythmia [RSA]) for infants and their mothers; 2) evaluate the initial impact of the intervention on observed feeding interactions, reported infant feeding behaviors and maternal feeding behaviors/beliefs, and infant nutritional intake and growth; and, 3) explore preliminary data on concordance between dyadic feeding interactions and autonomic regulation in both mothers and infants (RSA). In addition to a variety of self-report and anthropometric measures, this study will use integrated behavioral (video) and physiologic (RSA) measures to better understand feeding dynamics and their relationship with obesity risk. Understanding these processes is essential for developing appropriate preventions, or interventions, that will help reduce the prevalence of early childhood obesity and its extension into later childhood and beyond.

Principal InvestigatorCoretta Jenerette, PhD, RN, CNE, FAAN

Funded by: C. Felix Harvey Award to Advance Institutional Priorities (2016-2017)

Co-Investigators: None

Abstract: Not available

Principal InvestigatorCoretta Jenerette, PhD, RN, CNE, FAAN

Funded by: National Institute for Nursing Research (2014-2017)

Co-Investigators: Lloyd Edwards, Biostatistics; Kathleen Knafl, School of Nursing; and Rupa Redding-Lallinger, Pediatrics – Hematology/Oncology

Abstract: Sickle cell disease (SCD) is an autosomal recessive disorder affecting over 100,000 individuals in the US. Individuals with SCD often experience chronic pain as well as acute, unpredictable pain episodes requiring healthcare visits and hospitalizations. As adolescents with SCD transition into adulthood, they must be ready to competently self-manage their condition if they are to optimize health and health-related quality of life. Therefore, it is important to provide these adolescents (age 13-17 years) and their primary caregivers, most often mothers, with the tools to prepare for transition. In this proposed 2-year pilot study, we will evaluate the effectiveness of Project Sickle CIA (Cultivating Informed Activated Adolescents), a 5-week web-based intervention that addresses both the self-care management needs of adolescents with SCD and the significant role of mothers in cultivating competent emerging young adults. Our specific aims are to: (1) determine the feasibility (delivery, acceptability, and use) of the Project Sickle CIA intervention and (2) obtain preliminary estimates of the efficacy of the Project Sickle CIA intervention in improving adolescent outcomes in activation, health-related quality of life, and self-efficacy and maternal caregiver outcomes in activation, health-related quality of life, and maternal worry from pre to post intervention. The proposed study will use a non-randomized, prospective, longitudinal design with outcomes for both members of the adolescent-mother dyad, where 20 dyads will complete the 5-week intervention. Feasibility and acceptability will be measured by participation in website activities and feedback gained during postintervention individual interviews. The effectiveness of the intervention will be tested using multilevel linear mixed effects models for modeling each longitudinal outcome measured on both adolescent and mothers.

Principal Investigator: Kathleen Knafl, PhD, FAAN

Funded by: National Institute of Nursing Research (2011-2017)

Co-Investigators: Jamie Crandell, Jennifer Leeman, Margarete Sandelowski, and Julia Shaw-Kokot, UNC School of Nursing

Abstract: A substantial percentage of children have a chronic physical condition (CPC) such as arthritis or diabetes putting them at increased risk for psychosocial adjustment problems. Although much primary research has targeted families with these children, still unknown are the factors that prevent, ameliorate, or increase risk for children and families and how adjustment varies over time in this population. In addition, prior reviews of this research have been limited in their scope; focused on selected aspects of family response, conditions, or time periods; and limited to studies with pre-selected research designs. These delimitations have posed a barrier to synthesizing the primary research available to address important questions regarding such factors as the relationship of child development, disease course, and family structure to family response and child health outcomes. Knowledge of these risk and resistance factors is necessary to provide an evidence base for developing interventions that support optimal child and family outcomes. The proposed research synthesis addresses the limitations of prior reviews by fully mining the body of research addressing family life in the context of childhood CPCs via the use of state-of-the-art methods to integrate the findings from this research in collaboration with family researchers and clinical decision makers. The overall objective of the proposed study is to synthesize findings from empirical research addressing the intersection between family life and childhood CPCs. Bayesian meta-analysis and realist synthesis methods will be used to: (1) Map the relationships found among condition management and control; functioning of the affected child, parents, and siblings; family life and functioning; family relationship with the healthcare system; and individual and family demographics, (2) Explain how these factors operate together to produce variations in child and family outcomes, (3) Describe the nature of interventions directed to families of children with CPCs and their effects on child and family outcomes, and to (4) Examine factors mediating and moderating intervention effects. The outcomes of the proposed study will be evidence summaries addressing each of the four specific aims and theoretical integrations of findings that address the strengths of families with children with CPCs, the problems these families confront, and the rationale for interventions to enhance these strengths and address these problems. Study findings will be disseminated in forms accessible to and usable by both researchers and clinical decision makers. The proposed study addresses the National Institute of Nursing Research emphasis on Improving Quality of Life through support for research that generates knowledge of self and family management of chronic conditions.

Principal Investigator: Kathleen Knafl, PhD, FAAN

Funded by: National Institutes of Health via subcontract with Childrens National Health System, Children’s Research Institute


Abstract: Not available

Principal Investigator: Kathleen Knafl, PhD, FAAN

Funded by: National Cancer Institute via subcontract with University of Pennsylvania


Abstract: Not available

Principal Investigator: Shawn Kneipp, PhD

Funded by: National Institute on Minority Health and Health Disparities (2014-2017)

Co-Investigators: Donna Gilleskie, UNC Department of Economics; Todd Schwartz, UNC School of Nursing

Abstract: To date, studies of the criminal justice system and health have generally focused on disease transmission and health care services among incarcerated populations; however, incarcerated individuals account for only 3.5% of the 65 million adults with a criminal conviction in the U.S. When individuals are charged or convicted of a crime, a set of legal and social collateral consequences typically follow. These consequences may include life-long restrictions in employment opportunities and public benefit eligibility, and occur regardless of criminal offense severity or whether a person was imprisoned as part of their criminal sentence. These consequences disproportionately, and more adversely, affect disadvantaged women (i.e., those who are racial/ethnic minorities, and/or poor, and/or lower-educated), who typically commit misdemeanor-level crimes (e.g., non-payment for bad checks, traffic violations), rely on public benefits and low-wage, service-sector jobs to support themselves and their children, and have extremely poor mental and physical health. A large body of findings indicate that: (1) employment has an overall positive impact on health, (2) the primary welfare program for women in the U.S. (Temporary Assistance for Needy Families, or TANF) provides critical income support and job-placement assistance, and (3) women without stable sources of income often increase their health-risk behaviors to meet their food, shelter, and other basic needs. However, no research, to our knowledge, has integrated into one empirical analysis the interrelated relationships among the criminal justice system, the welfare system, and the labor market, to evaluate how they impact health disparities. Specifically, applying a systems science dynamic modeling approach consistent with the goals of PAR-11-315, we will explore the how the inability to access TANF and/or find employment due to having a prior criminal record may contribute to the persistently poor health status of this group.

The proposed study addresses this gap based on a secondary analysis of a nationally representative, 9-year longitudinal panel survey data set of 4,898 women from the Fragile Families Study. It is the first to explore whether, and how, collateral consequences operate across criminal justice, welfare, and labor market systems to influence women’s health. Motived by our prior community-engaged research, we will explore whether the presence, level of severity (charge, conviction, incarceration), and type (drug-, violence-, theft/fraud-, and traffic-related) of a criminal offense history affects employment patterns and health (psychological distress, depression, general health, and limited functioning) for women over time, and the extent to which TANF receipt moderates these relationships. Using the dynamic model to conduct a series of simulations, findings from this study will include projected health trajectories for women over time based on TANF and employment policy and program change scenarios. These findings could inform public health-oriented interventions to reduce adverse health outcomes for women with a criminal offense history.

Principal Investigator(s): Core: Alice Ammerman, Jennifer Leeman, DrPH, MDIV, and Sam Cykert; Center: Alice Ammerman

Funded by: Centers for Disease Control and Prevention via UNC Center for Health Promotion and Disease Prevention (2014-2019)



Principal Investigator: Jennifer Leeman, PhD, MDiv

Funded by: Centers for Disease Control and Prevention/National Institutes of Health (2014-2019)

Co-Investigators: Noel Brewer and Kurt Ribisl, Health Behavior; Stephanie Wheeler, Health Policy and Management

Abstract: Cancer has overtaken heart disease as the leading cause of death in North Carolina (NC), and disparities in cancer care and outcomes persist across racial, ethnic, and economic groups. To reduce cancer incidence and mortality, we will promote the adoption and implementation of evidence-based approaches (EBA) to cancer prevention and control (CPC). The Comprehensive Cancer Control Collaborative of North Carolina (4CNC) proposes to continue to contribute to the Cancer Prevention and Control Research Network’s (CPCRN) mission to facilitate uptake of evidence-based CPC interventions through research, training, and technical assistance. 4CNC has developed robust community-academic partnerships with researchers, care providers, and communities across North Carolina to promote the use of EBA to prevent cancer, increase screening, and enhance access to cancer care for all North Carolinians.  4CNC proposes to further develop its established organizational infrastructure to collaborate with CPCRN and with its strong local partners to accelerate the adoption of evidence-based CPC in NC communities and across the nation. We plan to move further along the discovery to delivery continuum by also engaging in research on how to disseminate and implement EBA to improve cancer outcomes among individuals, in communities, and across health care systems. We propose continuing our work to prevent and control colorectal cancer, eliminate disparities in breast cancer screening, prevent cervical cancer through increased HPV vaccination and reduce the impact of tobacco use. In partnership with CPCRN and our 4CNC local partners, our aims are:  (1) Maintain and enhance existing 4CNC infrastructure to (a) further develop local and CPCRN partnerships and activities, (b) identify and rapidly respond to priority areas and emerging issues, (c) initiate and support CPC, dissemination, and implementation research and evidence-informed practice, and (d) more rapidly and broadly disseminate 4CNC products and results to partners at the local, state, and national levels as well as to funding entities and CPCRN members; (2) Advance the science and practice of dissemination and implementation research across the cancer continuum with a focus on (a) preventing cervical cancer via HPV vaccine uptake, (b) eliminating disparities in breast cancer screening and treatment, and (c) preventing initiation and promoting cessation of tobacco use; and (3) Create a community and research-based infrastructure, including a cross-CPCRN project, to support and  inform implementation of Community Guide recommendations to increase CRC screening in NC, with a special emphasis on increasing use among minority and uninsured individuals.

Principal Investigator: Jennifer Leeman, DrPH, MDiv

Funded by: Centers for Disease Control and Prevention (2015-2017)

Co-Investigators: Alexandra Lightfoot and Mainhan Vu, Center for Health Promotion and Disease Prevention; Leslie Lytle, Health Behavior; Alice Ammerman, Nutrition

Abstract: The Centers for Disease Control and Prevention (CDC) School Health Branch (SHB) and others have developed a range of tools and resources to support public health, school, and other community-based practitioners as they translate research evidence into practice and thereby create school environments that are supportive of healthy behaviors. Tools and other resources can play a central role in translating research findings into products that practitioners might apply to improve practice. However, little is known about practitioners’ awareness, perceptions, or use of existing tools and resources, knowledge that is critical to improving existing tools and resources and creating new ones. We propose an evaluation that incorporates current paradigms in implementation science and utilizes a sophisticated sequence of quantitative and qualitative data collection methods to obtain a comprehensive picture of awareness, perceptions, and use of SHB tools among key state and local stakeholders. In the first phase of the evaluation, at least 100 local and state-level practitioners will be surveyed to assess their awareness, perceptions, and adoption of SHB tools and resources. Findings from the survey will inform the second, qualitative phase, which will involve 5 site visits to deepen understanding of practitioners’ use of SHB, what works well and what does not, and any unmet needs. We place our evaluation of school health tools and resources within the CDC’s Knowledge to Action framework. With K2A as a starting point, we conceptualize the SHB tools and resources of interest as examples of products that translate the findings from efficacy and effectiveness studies into resources that can be used to promote dissemination, adoption, implementation and sustainability (maintenance).  We focus on three components of K2A’s translational phase, dissemination, decision to adopt, and implementation, and extend our inquiries into the sustainability phase as well. The K2A framework is one conceptual tool for organizing our evaluation. The other frameworks we draw on are project director Leeman’s capacity building framework and Wandersman’s Interactive Systems Framework, providing a robust conceptual and theoretical context for building our measurement protocols and analysis plans.

Principal InvestigatorMary R. Lynn, PhD

Funded by: National Council of State Boards of Nursing (2016-2018)

Co-Investigators: Cheryl Jones, UNC School of Nursing

Abstract: Within the last 15 years hundreds of transition programs for new graduate registered nurses (NGRNs) have been launched yet, to date, no study has been located that characterizes these programs or compares them on essential components such a length, content, structure or outcomes. Yet transition programs are in place in virtually every hospital in the U.S. This project has been designed to fill that gap.  This study will be done in two phases, each done collaboratively with a 10-member Advisory Board. The Advisory Board members represent a diverse population all with interests in transition programs – four head staff development departments, three of which have transition programs in their department, one is a chief nursing officer whose hospital started its own program, one in a clinical researcher involved in a national transition program, another an academic research who studies new graduate registered nurses, and the remaining members are a national-expert in nursing education, a sociologist with research experience in nursing-related workforces, and the director of a large national transition program. In Phase I, 1,400 U.S. hospitals will be randomly sampled from the AHA list of hospitals and their nursing education director asked to complete an assessment of their program for transitioning nurses as well as to provide characteristic data about their hospital. The Advisory Board will work to develop a schema to classify the transition program in 2 to 3 major characteristics (e.g., length, content) which will then have sub-categories developed. These will, in turn, be used for the sampling for Phase II where a hospital within each “cross-category” will be contacted and asked for the opportunity to recruit up to 24 new graduate registered nurses (540 NGRNs is the desired final sample) to complete several outcome instruments at the beginning, middle and end of their first year of employment.  All data collection will occur online. The questions to be addressed include identifying the characteristics of transition programs for new graduate registered nurses in the U.S., exploring the relationship between variable in the domains of the NGRN, the program and the hospital, comparing NGRN across time and classification categories, and attempting to predict the NGRN outcome measures from the program and/or hospital characteristics. This study has implications in terms of the knowledge to be gained about transition programs in nursing and to inform regulatory bodies about the characteristics to consider if these programs are to be required before a nurse is “fully licensed.”

Principal Investigator: Britt Pados, PhD, RN, NNP-BC

Funded by: National Association of Neonatal Nurses (2016-2017)

Co-Investigators: Suzanne Thoyre, UNC School of Nursing

Abstract: Feeding difficulty is common in young infants and includes behaviors such as feeding refusal, irritability, lengthy feeding, coughing, and gagging. The number of infants with feeding difficulty has risen with the increasing survival of critically ill newborns, such as those born premature and with congenital heart disease. Feeding difficulty is problematic because it results in suboptimal nutrition during a critical time for brain development, impacts the child’s long-term behavioral responses to food, and affects the developing parent-child relationship Early implementation of treatment to optimize nutrition and feeding skill development is critical, but differentiation between typical and problematic feeding behaviors is challenging. No valid and reliable assessment tools are currently available for use with breast- and bottle-feeding infants from birth to 6 months of age. The purpose of this study is to assess the psychometric properties of the Neonatal Eating Assessment Tool (Neo-EAT), a parent-report tool that is currently in development to assess feeding difficulty in breast- and/or bottle-feeding infants from birth through 6 months.

Principal Investigator: Sheila Santacroce, PhD, RN

Funded by: Alex’s Lemonade Stand Foundation, Nurse Discovery Award (2014-2017)

Co-Investigators: Jamie Crandell, UNC School of Nursing

Abstract: Chronic psychosocial stress is a universal feature of the childhood cancer experience,6 and ongoing illness uncertainty is a main source of this stress.13 Extensive evidence associates chronic psychosocial stress with cardiovascular (CV) disease, especially in people with lower socio-economic status (SES) or psychological symptoms.10 These factors can exist in children who present with cancer, and the traumas that are inherent in childhood cancer can promote anxiety and posttraumatic stress symptoms/PTSS.6 On the other hand, patients 21 and survivors 23, 24 have also been shown to find benefit in having been through childhood cancer. While the exact mechanisms remain unclear, psychosocial stress has been shown to provoke systematic inflammation as measured by c-reactive protein (CRP), 10 including in vascular endothelial. Chronic psychosocial stress and systemic inflammation in turn can lead to arterial stiffness, which is an important clinical predictor of CV disease in the general adult population independent of blood pressure (BP). 10 Pulse wave velocity (PWV), that is, the rate at which pressure waves move out of the left ventricle (LV), into the aorta and throughout the arterial bed is the gold standard measure of arterial stiffness.7

Because CV disease is the major non-cancer cause of death among its survivors, 3 linkages between psychosocial stress and CV disease are especially important for childhood cancer patients and survivors. The class of chemotherapeutic agents known as anthracylines (e.g., doxorubicin, daunomycin, idarubicin) has long been associated with CV toxicity including LV dysfunction, cardiomyopathy and sudden onset or progressive heart failure, likely because the anthracyclines are effective against many childhood cancers and have been widely used.2 Risk factors for anthracycline-related CV-toxicity include female gender, history of CV disease, younger age (< 5 years) when treated, higher total anthracyline dose and radiation to a field comprising the heart.5, 6 Risk for CV toxicity/disease might also be exacerbated by psychosocial stress-related elevations in CRP and resultant arterial stiffness that further burden the LV that is already working to compensate for anthracyline-related oxidative stress, myocardial damage and cardiomyocyte death.8 Pediatric reference values have been established for PWV measured by applanation tomometry in healthy children, 22 and PWV is now being examined in various pediatric populations at risk for CV disease, for example, children with type 1 or type 2 diabetes, polycystic ovary syndrome (PCOS), chronic renal disease or systemic lupus. Two papers have reported information about PWV in children who received an anthracycline at least 1 year ago. In both of these studies, PWV was measured at one point in time.11, 12 In adults with cancer, PWV has been found to be elevated at 4 months post-anthracyline exposure but its course was not described further.4 We are not aware of any published studies that have examined the course of PWV or whether uncertainty, anxiety, PTSS, benefit finding and systemic inflammation/CRP can affect PWV in childhood cancer patients or survivors. The purpose of this study is to describe PWV in a sample of children aged 8 to 17 years who recently completed a cancer treatment regimen that included an anthracycline. Data will be collected at 3 time points (T1: within 2-3 months post treatment completion; T2: 6 months post treatment; T3: 9 months post treatment). While acute inflammatory responses to treatment exposures could be expected to wane during this time, the transition from active treatment is a time of heightened psychosocial stress, which could affect both CRP and PWV.

Principal Investigator: Sheila Santacroce, Jennifer Leeman

Funded by: National Institute of Nursing Research (1996-2021)


Abstract: The purpose of this research training grant renewal application is to prepare nurse scientists with capacities to develop theory-based interventions for preventing and managing chronic illness with a new emphasis on accelerating translation into practice. The T32 has matured over the last 20 years of funding; its focus has expanded to address emergent priorities in research on theory-based interventions for preventing and managing chronic illness as well as to reflect the strength and diversity of our faculty research. In this application, we address the imperative to speed the translation of research findings to practice for the improvement of patient and population health outcomes. The program is conceptualized around a paradigm that posits two approaches to speeding translation: designing interventions with implementation in mind and applying rigorous approaches to disseminating and implementing research findings. Our continued focus on theory-based interventions will be enhanced by a new focus on translational science and training in five translation catalysts: dissemination and implementation science, stakeholder engagement, patient-centered outcomes, pragmatic and adaptive trial designs, and mixed methods. For predoctoral trainees, enhancements to the PhD program will include: courses structured to address the five translation catalysts; mentored research experiences; and participation in seminar series concentrated on development as a scientist and on promoting translation of intervention research to practice. For postdoctoral trainees, the training program also will include independent research experiences and active involvement in interdisciplinary seminar series. A total of 14 predoctoral trainees and 10 postdoctoral trainees will be supported over the 5 years of the training program. The emphasis on the five new areas will capitalize on our faculty strengths, strong research infrastructure, and well-established partnerships on The University of North Carolina at Chapel Hill campus and throughout the rural and racially diverse state of North Carolina.

Principal Investigator: Hudson Santos, PhD, RN, UNC School of Nursing; Benjamin Nephew, Tufts University Department of Biomedical Sciences

Funded by: The North Carolina Translational & Clinical Sciences Institute (2016-2017)


Abstract: Latina immigrant mothers face acculturative stress, discrimination and financial hardship in the US, putting them at increased risk for poor mental health. This combination of stressors can have deleterious effects on their outcomes and the outcomes of their US-born children.1-3 Immigrant women are twice as likely as non-immigrant women to experience severe post-partum depressive symptoms (PPDS).4 Indeed, in the US, up to 59% of Latina mothers experience moderate-to-severe PPDS.5-7 Despite this high prevalence, cultural attitudes toward treatment can bar Latinas from seeking care for mental health issues.8 The long-term detrimental effects of maternal PPDS on children, including behavioral and developmental deficits, are well-established.9 Since Latinos have the highest fertility rate10 and are the fastest growing minority group in the US (111.1% increase in NC from 2000 to 2010),11 it is crucial to understand factors that predict the mental health status of childbearing Latinas, thereby allowing us to target early interventions, avert costs from adverse effects, and alleviate multi-generational health disparities.

One promising predictor of postpartum mood is oxytocin (OXT), a neuropeptide essential to labor, birth, lactation and facilitation of mother-infant bonding.12-14 Lower prenatal plasma OXT levels have been strongly associated with increased risk for PPDS in Swiss mothers.15 Further, decreased plasma OXT levels have been correlated with higher PPDS and anxiety symptoms in US middle-income non-Latina mothers.16 Moreover, there is early evidence that epigenetic modification (methylation) of the OXT receptor gene OXTR promoter reduces OXTR expression, resulting in lower OXTR levels, and that this methylation may be a biomarker for PPDS.17 However, whether prenatal OXT levels predict PPDS in Latina mothers is unknown. In this multi-CTSA study, therefore, we will engage experts in Latino health, perinatal mental health, endocrinology and genetics to address this gap.

Principal Investigator: Lixin Song, PhD, RN

Funded by: National Cancer Institute, National Institutes of Health (2016-2018)

Co-Investigators: Deborah Mayer and Josephine Asafu-Adjei, School of Nursing; Ronald Chen, School of Medicine; and Sarah Birken, School of Public Health

Consultant: Laurel Northouse, University of Michigan

Abstract: Supporting NIH’s mission, this project aims to explore a new model of care that enhances survivorship care planning and promotes health for patients with localized prostate cancer (PCa) transitioning to post-treatment self-management. Survivorship care planning for patients with PCa is important because of the high incidence rates of PCa in the U.S., the frequent occurrence of treatment-related side effects, and reduced quality of life (QOL) in both patients and their partners (for patients who are partnered). Emerging evidence suggests that use of regular survivorship care plans (SCPs) does not improve health service and patient outcomes because the content in mandated SCPs does not consider patients’ information and care needs. We plan to integrate an evidence-based, theory-driven symptom self-management program, Prostate Cancer Education & Resources for Couples (PERC), with standardized SCPs and build enhanced SCPs (ESCPs). ESCPs will engage both patients and partners during survivorship care planning and provide a one-stop, comprehensive PERC program to improve their QOL and decrease patient use of post-treatment care services. The couple-focused, web-based tailored PERC program includes 12 online modules with assignments, a moderated chat room and a resource center. Tailored to patients’ and partners’ characteristics and preferences to address their specific care needs, PERC helps couples reduce negative appraisals of symptoms, increase access to social support, and enhance self-efficacy and health behaviors for symptom self-management. In this study, we propose to test the feasibility of ESCPs (regular SCPs with the PERC web link) and to conduct an initial benefit assessment of ESCPs. We will use a two-group (ESCP=intervention and SCP only=negative control) randomized controlled pretest-posttest design and collect data at baseline (T1) and 4 months later (T2) among 50 patients completing initial treatment for localized PCa and their partners. The specific aims are: Aim 1: Examine the feasibility of delivering ESCPs (as assessed by recruitment, enrollment, and retention rates, satisfaction with ESCP, and perceived ease of use of PERC). We will use mixed methods to achieve this aim. Aim 2: Estimate the magnitude of benefit of ESCPs. We hypothesize that, compared with the SCP only users, the ESCP users will report (1) greater improvement in their primary outcomes of QOL (overall, physical, emotional, and social QOL); (2) greater improvement in secondary outcomes (reduction in negative appraisals and improvement in self-efficacy, social support, and health behaviors to manage symptoms); and (3) fewer visits to post-treatment care services from between T1 and T2. The results from this study will help design a definitive randomized trial to test the efficacy of ESCP. The innovative ESCPs will strengthen survivorship care planning and allow PERC to be disseminated broadly and systematically without the need for costly resources or personnel. This proposed project is in response to calls for programs from the Institute of Medicine and American Cancer Society to address treatment-related effects and help cancer survivors maintain their QOL.

Principal Investigator: Mark Toles, PhD, RN

Funded by: North Carolina Translational & Clinical Sciences Institute (2014-2017)

Mentors: Laura Hanson, UNC Chapel Hill School of Medicine; Cathleen Colon-Emeric, Duke University; Mary Naylor, University of Pennsylvania; Jennifer Leeman, School of Nursing & Laura Hanson, School of Medicine

Abstract: The purpose of this KL2 Mentored Career Development Award is to promote the development of Mark Toles, PhD, RN as an independent investigator testing transitional care interventions in nursing homes, e.g., interventions designed to support transitions in care for Medicare beneficiaries who use the skilled nursing facility (SNF) benefit for short stays in nursing homes and then transfer to home. Dr. Toles’ long-term career goal is to become an independent clinical investigator and leader in the study of transitional care for SNF patients in nursing homes. To achieve this goal, the proposed mentored research for this KL2 award is to design and test the feasibility and acceptability of a transitional care intervention in three nursing homes. To support this research and Dr. Toles’ long term goal, this KL2 application includes mentored training through coursework and mentored independent studies to address three training goals: (a) achieve the ability to design and conduct clinical intervention research in nursing homes; (b) develop scientific expertise in using theories of organizational change to guide intervention design for SNF patients in nursing homes; (c) design and pilot test a transitional care intervention matched to the needs of SNF patients in nursing homes. This training will be applied to research with two specific aims: (Aim 1) collaborate with stakeholders and experts to design an intervention that uses existing staff in nursing homes to deliver transitional care to SNF patients and their family caregivers for transitions to home; (Aim 2) in a study using a pre-post test design, test the feasibility and acceptability of the intervention and changes in measures of transitional care processes and patient outcomes. The mentoring team is ideally suited for the proposed KL2 training and research; it provides access to experts in clinical intervention research in nursing homes, organizational change in nursing homes and transitional care interventions. Completion of the career development plan and proposed research will inform the development of an R01 application and ensure Dr. Toles’ ability to conduct independent research on transitional care with SNF patients in nursing homes. The study has significant public health relevance. Every year nearly 2 million older Americans enter nursing homes for SNF care before their transitions to home-based care. In the absence of effective nursing home to home transitional care, nearly half of them now die or return to the hospital within 90 days. Innovative approaches to prepare SNF patients and their family caregivers for transitions from nursing homes to home are needed. The proposed KL2 training and research are significant because they will facilitate Dr. Toles’ development as an intervention researcher in nursing homes and provide a model for improving transitional care in nursing homes with the potential for wide implementation and benefit to older adults.

Principal Investigator: Mark Toles, PhD, RN

Funded by: Hartford Practice Change Leaders (2017)

Advisory Group: Jennifer Leeman, UNC School of Nursing & Laura Hanson, UNC School of Medicine

Abstract: The proposed PCL project “Connect-Home” will develop and establish quality improvement methods to sustain transitional care in SNFs. The project will (a) gather data to describe the business case for sustaining services, (b) create an adaptable model for sustaining care in other SNFs and organizations, (c) develop new opportunities for integrating LSC with key community partners (i.e., hospitals with bundled care demonstrations), and (d) disseminate lessons learned in national forums such as Leading Age and Lutheran Services America.

Principal Investigator: SeonAe Yeo, PhD, RN, FAAN

Funded by: UNC Center for Diabetes Translation Research to Reduce Health Disparities



Principal Investigator: Jessica Zegre-Hemsey, PhD, RN

Funded by:  The North Carolina Translational & Clinical Sciences Institute (2016-2017)

Mentors: Wayne Rosamond, George Stouffer, and Debra Moser

Abstract: ST-elevation myocardial infarction (STEMI) is a significant health problem in the United States, and rapid diagnosis and life-saving reperfusion therapies are essential to prevent devastating outcomes.  Dr. Zègre-Hemsey has extensive clinical experience in the emergency department, where she became passionate about improving care for patients with acute coronary syndrome (ACS), and specifically with STEMI.  In her dissertation research, Dr. Zègre-Hemsey investigated prehospital electrocardiography (PH ECG) to improve early diagnosis of ACS, which provided foundational support for the proposed study and her emerging program of emergency care research.  The KL2 is the logical next step to support Dr. Zègre-Hemsey’s long-term goal of becoming an independent cardiovascular nurse scientist, and her outstanding mentoring team will be pivotal to her career development.  Wayne Rosamond, PhD (primary) is a prominent researcher in cardiovascular epidemiology and emergency medical services research (EMS).  He has an extensive history of sustained funding and successful mentorship of numerous junior faculty.  George Stouffer, MD (co-mentor) is a distinguished professor of cardiology and expert in interventional cardiology research with a record of continued funding and successful mentoring.  Debra Moser, PhD, RN, (co-mentor), is a renowned nurse scientist with expertise in prehospital delay of ACS patients, and has a history of continued funding and mentoring of junior faculty.  In the proposed research, Dr. Zègre-Hemsey will acquire new skills in the use of large datasets (“big data science”) and advanced knowledge of intervention development through coursework, mentoring, and active engagement with established research teams.  The study will investigate the accuracy of current electrocardiographic methods for prehospital STEMI interpretation, and develop an intervention to improve prehospital STEMI detection.  Specific aims are:  Aim 1: Examine current EMS practice and protocols for PH ECG interpretation. Aim 2: Determine the diagnostic accuracy and time to conduct each PH ECG interpretation method. Aim 3: Design and test the feasibility of an educational intervention for EMS providers to improve the diagnostic accuracy of PH ECG for rapid STEMI diagnosis.  A mixed-methods descriptive study design will be implemented with a sample recruited from 1) EMS agencies across the state of North Carolina, one of four places in the United States that has an established PH ECG program, and 2) a novel cardiac registry that links prehospital data elements with hospital outcome data.  Based on these, an R21 will be developed in Year 3 of the award to pilot-test the intervention. This patient-oriented study is feasible and congruent with NIH’s strategic plan and priorities to support big data science using large datasets and innovative technologies in emergency care research.  The long-term impact of this study would be improved triage, risk stratification, and access to life-saving strategies for STEMI patients to improve overall survival, functional status, and quality of life.