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Used Social Action Theory to describe and explore sexual risk behaviour
The sexual transmission of HIV is complex and multi-factorial. Social Action Theory provides a framework for viewing self-regulation of modifiable behaviour such as condom use. Condom use is viewed within the context of social interaction and interdependence.
Self-report questionnaire administered to adults living with HIV/AIDS, recruited from clinics, service organizations and by active outreach, between 2010 and 2011.
Having multiple sex partners with inconsistent condom use during a three-month recall period was associated with being male, younger age, having more years of education, substance use frequency and men having sex with men being a mode of acquiring HIV. In addition, lower self-efficacy for condom use scores were associated with having multiple sex partners and inconsistent condom use.
Social Action Theory provided a framework for organizing data from an international sample of seropositive persons. Interventions for sexually active, younger, HIV positive males who have sex with men, that strengthen perceived efficacy for condom use, and reduce the frequency of substance use, may contribute to reducing HIV-transmission risk.
Both nationally and globally, the most frequently reported HIV-transmission risk behavior among newly diagnosed HIV-positive adults is sexual activity with a partner known to have, or be at risk for the virus (Centers for Disease Control and Prevention [CDC] 2013). Examples of HIV-transmission risk behaviors of seropositive persons include engaging in sex without the use of a condom and having multiple sexual partners (SPs). Condom use has been found to be up to 95% effective in reducing HIV incidence when used correctly and consistently (McKay 2007). However, many persons find condom use challenging for a variety of contextual, psychosocial and intrapersonal reasons. Reports indicate that up to two-thirds of sexually active persons living with HIV (PLWH) engage in HIV-transmission risk behavior, including not using condoms consistently (Reece et al. 2010, Reilly, et al. 2010). Since the incidence of new cases of HIV has not abated, there is a need to identify factors influencing transmission-risk behaviors among seropositive persons. One aim of our research was to explore factors influencing sexual risk behaviors in a sample of PLWH in the United States and Puerto Rico.
Sexual risk behavior among HIV-positive persons is multi-factorial and complex. Contextual, psychosocial and intrapersonal factors can moderate personal perceptions and beliefs about condom use (CU) and subsequent CU behavior. Social Action Theory (SAT) has been identified as a pragmatic model to use when exploring transmission-risk behavior among PLWH (Traube et al. 2011). SAT was developed as a health promotion theory for behavioral medicine (Ewart, 1991). Using this theory, we propose that consistent condom use is a client-initiated health-protective action/behavior resulting from interactions among three domains (Figure 1). The domain of contextual influences includes biologic/background factors, and social /environmental influences that affect mood and arousal state, that may contribute to perceptions or motivations to behave. The self-change processes domain includes motivational and generative capabilities that are self-regulated and thus modifiable. The domain of action states incorporates influences of social interdependence on the maintenance of health-related behaviors (Ewart 1991; Gore-Felton et al 2005). Individual action includes the self-regulation of modifiable health promoting and endangering behaviors, such as condom use, that occur within a context of social interaction and interdependence. Self-regulating behaviors are of interest in disease prevention because they are amenable to change. SAT allows for multidimensional targeting of behavior and has been useful for exploring influences on health behaviors including: identifying correlates of medication non-adherence (Johnson et al. 2008); exploring condom use among substance users in treatment (Reynolds et al. 2010); and, HIV-testing and condom use for commercial sex workers (Chiao et al. 2009). Traube et al. (2011) completed a thorough exploration and analysis of several health-promotion models that operationalize constructs and pathways for predicting behavioral health outcomes, and concluded that SAT was a useful framework to address HIV transmission-risk behavior. There is a need to further explain contextual and social processes influencing HIV transmission-risk behavior. This paper was framed using a SAT model.
The role of contextual influences in predicting HIV sexual transmission-risk behavior has garnered interest in the research arena, including background factors (gender, age, ethnicity), biological indicators (HIV disease progression), arousal/mood (anxiety and depression), and environmental contexts (life stressors, education).
Gender is of particular interest in HIV transmission research. In a multisite study (Weinhardt et al. 2004) that included seropositive men and women (n = 3,723), nearly one quarter of the women (21.2%) and heterosexual men (27.5%) and nearly sixty percent (59.4%) of the men who have sex with men (MSM) reported having multiple SPs. This is consistent with rates (26.4%) reported by the CDC (2012b) about sexually active adolescents. From a perspective of age, HIV prevalence is increasing rapidly among young people between ages 13–29 years, and particularly among MSM in this age group (CDC, 2014). However, many older PLWH also engage in behaviors that confer risk of HIV (Illa 2008; Onen 2010). When comparing self-reports of younger and older adult PLWH from Washington state (n = 541), rates of recent sexual activity decreased with age, but sexually transmitted diseases were evident among all age groups in this mostly African American and Caucasian sample (Onen 2010). Overall, about one third of the participants reported inconsistent condom use (CU) that did not differ by age group. The HIV-disease indictor of time since testing positive was not a significant predictor of CU in this cohort. A lower frequency (20%) of inconsistent CU was reported in a cohort of older sexually active PLWH from Florida (Illa et al. 2008). In addition, negative mood and perceived HIV stigma were associated with inconsistent (82%) CU in this group of mostly (60%) African American men. Among a sample of HIV-positive older African American men (Coleman & Ball, 2007), having fewer HIV symptoms and being single were perceived barriers to condom use.
Aspects of mental health involving mood and arousal have been explored among PLWH related to sexual transmission risk behaviors (Comulada et al. 2010; Kalichman & Weinhardt 2001). Negative affective states including social anxiety and depression have been identified as behavioral risk factors associated with unprotected sex among MSM (Beck et al. 2003; Mill et al. 2004). However, such findings have been equivocal across studies, where associations between sexual risk behavior and negative emotional states were not robust (Crepaz & Marks 2001), and where, on the other hand, depression was associated with sexual risk behavior (Kalichman 2000), and sexual compulsivity correlated with depression and anxiety (Kalichman, et al. 2001). In a clinic sample (n = 209) of mostly unemployed African American MSM, a strong association between social anxiety and unprotected insertive anal intercourse with sero-discordant partners was reported (Hart et al. 2008). Further examination of mechanisms by which anxiety is associated with sexual risk among seropositive MSM was recommended.
SAT expands upon social cognitive theories (Bandura, 1994) to target contextual and environmental influences as they relate to health protective/endangering behaviors (Moore & Oppong 2007; Traube et al. 2011). Life stressors have been considered when exploring sexual risk behavior. In a longitudinal study among PLWH in the Southeastern U.S. (n = 611), the association between stressful life events and unprotected sex was explored (Pence et al. 2010). Each additional moderately stressful event an individual experienced above his/her norm, was associated with increased odds (24%–27%) of engaging in unprotected sex. Stressful life events have also been associated with antiretroviral adherence (Corless et al. 2013). Adherence to antiretroviral medications is now considered a form of HIV prevention (Kalichman et al. 2011). Allen et al. (2010) explored factors associated with CU among PLWH in the Caribbean. CU at last sexual encounter was positively associated with education level. Economic security, measured by ‘having enough income,’ was also independently associated with CU. Weeks et al. (2009) explored the adoption of female CU among African American and Latina women in Connecticut (n = 461). Among other findings, higher education was associated with higher frequency of female CU.
Self-Change processes include the domains of motivational appraisals, social interaction processes and generative capabilities. In contrast to the above findings, Moskowitz and Seal (2011) reported no relationship between self-esteem and CU behavior among mostly white MSM (n = 1,468) from the Chicago and Wisconsin areas. With these equivocal findings for CU among MSM, further research is needed to determine if self-esteem, social support, and stigma are self-change processes related to transmission-risk behaviors, that clinicians can address through treatment interventions. Optimism about treatments that reduce HIV viral load has led to scientific inquiry about the role of optimism in the frequency of HIV-transmission risk behavior (Abelson et al. 2006; Peterson et al. 2012; Prestage et al. 2012; Vanable et al. 2003). Research thus far exploring this link among MSM has been inconclusive (Abelson et al. 2006; Peterson et al. 2012). A meta-analysis of treatment optimism reported no increase in transmission-risk among PLWH receiving treatment, compared to those who were not (Crepaz, et al. 2004). However, use of different measures may have contributed to divergent findings (Brennan et al. 2009).
Self-efficacy is an important motivational process highlighted in SAT, and a central construct in other explanatory models for health behavior (Kalichman et al. 2001; Sullivan 2009). Self-efficacy is a self-evaluative belief that one can effectively perform a specific behavior (e.g., use condoms) under specific conditions (e.g., a new partner, substance use). Behavior change is optimized when beliefs are strengthened about one’s capability for performing a recommended action. Self-efficacy for condom use differed significantly by gender in a sample of HIV-positive injection drug users (Mizuno et al. 2007). Lower self-efficacy for condom use and more episodes of partner violence were associated with negative beliefs about condoms among women but not men. Knipper et al. (2007) explored correlates of CU among heterosexual Latino men in rural North Carolina (n = 222). Efficacy measures included impulse control, partner resistance, and communication about condoms. Higher CU self-efficacy was associated with more frequent CU. These findings highlight the importance of using context-specific measures of efficacy for condom use (Mizuno et al. 2007; Kalichman et al. 2001).
The influences of stigma and social support have frequently been explored in sexual risk behavior among MSM (Mahajan et al. 2008). In two samples of MSM, higher stigma scores related to low self-esteem, and increased risk-taking behavior (Preston et al. 2007; Stokes & Peterson 1998). Perceived stigma has been correlated with depression also (Vyavaharkar, et al. 2010). HIV-related stigma was negatively correlated with self-esteem and positively correlated with social support (Adam et al. 2005; Rosario et al. 2006).
Action state outcomes include social-interdependence, and health protective/destructive behaviors.
Sexual transmission of HIV is dependent on the interchange between two sexually active persons. Relationship status is frequently measured in sexual risk behavior research (Sullivan et al. 2010; Wilson et al. 2007). HIV-positive women recruited from five U.S. cities (n = 1,090) used condoms less frequently in established partnerships as compared to newer ones (Wilson et al. 2007). Similar results were reported among women (n = 88) from Hawaii (HI) and Seattle, Washington (WA) (Sullivan & Voss 2009), who reported 139 total most recent partners.
For this SAT model, the health protective action of condom use is included in the outcome measure under study. Consistent condom use by PLWH is essential for reducing the chance of HIV transmission. Multiple factors may influence condom use including the aforementioned variables in the SAT model.
From this SAT framework, substance use is viewed as a habit that can moderate sexual risk behavior. Sexual risk-taking is known to increase in the context of substance use, as indicated by the association of drug use and having multiple partners (Duru et al. 2006; Simoni et al. 2000); and alcohol and/or drugs before engaging in unsafe sex (Marks & Crepaz 2001).
Based on a thorough review of the literature grounded in SAT, sexual risk behavior is considered multi-factorial, and influenced by contextual factors, by arousal and mood states, and by social, motivational, and interaction processes. Coupled with inconsistent findings about contextual, social, and self-change processes predicting sexual risk behavior, this review suggests that further investigation is needed. The aims of this study were to explore factors associated with sexual behavior that incur HIV transmission-risk, including having multiple SPs and inconsistent condom use over a short period of time (three months). Framed in SAT, factors considered to influence HIV transmission risk behavior are provided in Figure 2.
The primary purpose of the multisite international study was to explore aspects of Self - (efficacy, esteem) - in relation to disease self-management, among PLWH. This paper includes secondary analyses of data on sexual risk behavior from participants (n = 1773) at research sites across the U.S. (n = 16) and Puerto Rico (n = 1). The aims of this analysis were to:
The study included a cross sectional descriptive survey developed by the International Nursing Network for HIV/AIDS Research (Holzemer, 2007). Convenience samples of adult PLWH were recruited from study sites located nationally and internationally. Sample size was determined by each principal investigator contributing data sets with at least one hundred participants.
Inclusion criteria consisted of: being 18 years of age or older; having an HIV-positive serostatus (self-report); being able to provide informed consent to participate; being literate based on the predominant site/country. Exclusion criteria consisted of an inability to provide informed consent as evidenced by cognitive impairment, active psychosis, or significant confusion. Participants responded to advertisements and/or active outreach at HIV/AIDS health care and social service sites, private practices, university-based clinics, and public or private facilities.
Data were collected using a hard-copy questionnaire. Participants could ask for assistance from survey administrators if needed to complete the survey. Data collection between February, 2010 and July, 2011. Assessment measures were chosen based on the SAT framework and will be described using the model provided (Figure 1). Most assessment measures have previously been used and validated with HIV participants unless otherwise specified. A description of the scales used for these measures are presented (Figure 2).
The study was approved by Institutional Review Boards (IRB) at the universities and/or health agencies at each site.
Descriptive data included: frequencies by gender of categorical variables (Table 1); frequencies and means by sexual risk behaviors, including: a) had sex; b) had sex without a condom, and; c) had sex with more than one partner (Table 2 and Figure 3, respectively). Multivariate logistic regression modeling was used to identify variables in the SAT model that predicted four distinct outcomes: 1) had more than one SP without consistent condom use (Table 3); 2) had sex;3) had sex without a condom; and 4) had sex with multiple partners (Table 4);. Background factors were initially entered, including sex, age, ethnicity, years HIV positive, AIDS status, and transmission risk category. Then, using a forward step modeling procedure the remaining variables in the SAT model were entered. Level of significance was determined to be values of p ≤ 0.05.
The instruments and measures are categorized by the SAT model (Figure 2). Cronbach’s alphas are provided for measures of reliability where indicated.
Participant data from 1,773 persons were included in this sub-analysis (Table 1). The majority of participants were male (71.9%, n = 1,264), as fewer females (n = 491) from the U.S. and Puerto Rico were enrolled.
The participants were mostly of African American (43.2%), Caucasian (25.0%) or Hispanic/Latino (24.2%) ethnicity. Over two-thirds of the men (67.7%, n = 787), and most of the women (84.7%, n = 394), reported that they contracted HIV by having sex with an HIV-positive male. Most participants reported having a diagnosis of HIV rather than AIDS (55.8% vs. 42.9%, respectively). About one-quarter of the participants did not have a high school diploma or equivalency (n = 442), while over one-third had some college education (34.1%, n = 597). Less than one in five participants worked for pay (19.6%, n = 341), and the majority reported income as less than adequate (79.1%, n = 1,372). The age range of the sample was 18 – 74 years, with mean age for men (46.4) slightly older than for women. Mean number of years living with HIV/AIDS was slightly longer for men than women (14.3 and 13.0 years, respectively).
Table 2 presents data on frequencies including: 1) had sex; 2) had sex without a condom; 3) and had sex with more than one partner. SAT factors are explored in light of these behaviors. Of the men and women who reported about sexual relationships (n = 1,557), over half engaged in anal or vaginal sex during the previous three months (51.1%, n = 896). Nearly one quarter (24.7%) had sex without a condom, and over two hundred (n = 237) had multiple SPs, with most of those being male (n = 214).
Within ethnic groups, over half of the participants of Asian/Pacific Islander, African American and Hispanic/Latino descent reported engaging in sex (56.0%, 54.2% and 53.9%, respectively). However, the frequencies of engaging in sex without a condom were highest among Asian/Pacific Islanders (30%), and the reported frequency for having sex with more than one partner was highest among those in the Caucasian ethnic group (15.1%). Participants who reported MSM as the transmission route for their HIV disease, more frequently reported having sex, having inconsistent condom use, and having multiple sexual partners, compared to participants who reported other modes of HIV transmission.
Levels of education categories indicate that the frequency of reports of inconsistent condom use was highest among participants with college experience (29.5%), compared to those with less education (22.3% and 22.1%, respectfully). The report frequency for having sex with more than one partner was ten-fold higher among those with college experience (19.9%), compared to those with less than a high school diploma or equivalency (9.5%). A majority of participants who worked for pay reported they had sex (60.4%), while a minority (48.5%) of those who did not work for pay had sex during the 3-month recall period. Report frequencies for having sex without consistent condom use, and for having sex with more than one partner, were higher among those who worked for pay (30.6%, 19.1%, respectively), compared to those who did not (23.1%, 12.1%, respectively).
For frequency of substance use, participants who abstained from substances reported lower frequencies of engaging in sexual risk behaviors (using condoms inconsistently, and/or having multiple SPs). Participants who frequently used substances, also more frequently reported having sex without condom use, and having sex with multiple partners.
Figure 3 presents mean scores for SAT model factors among participants who engaged in the behavior categories of: no sex; had sex; had sex without a condom; and had more than one SP without consistent condom use. For those who reported no sex, mean age, and mean years HIV-positive were higher, compared to all other sex-behavior categories. In addition, mean scores for the arousal and mood indicators of anxiety and depression were lower among persons who reported no sex. Higher mean scores for depression, anxiety and number of stressful life events were reported among persons who had multiple sex partners without consistent condom use.
Mean scores for personalized HIV stigma, social support; and treatment optimism, were similar across sexual behavior categories. Self-esteem scores were highest for participants who reported having multiple SPs. The lowest mean scores for condom use self-efficacy were among the sexual behavior categories of having sex without using a condom.
Using binary logistic regression (forward selection), all aforementioned factors were included in 3-block modeling procedures for the outcome variable of had sex with multiple partners without consistent condom use (Table 3). For comparison, similar modeling procedures were used for the outcome measures of: had sex, had sex without a condom, and had sex with multiple partners (Table 4).
The following indicators were predictive of the HIV-transmission risk behaviors of engaging in sex with multiple partners without consistent condom use: sex, age; mode of HIV-transmission; level of education; self-efficacy for condom use, and substance use frequency.
Females were less likely than men to engage in sex with multiple partners and without consist condom use (β = −1.06, p =.05). Age was significant, such that as age increased, the likelihood of having multiple SPs without consistent condom use decreased (β = −0.04, p =0.01). Mode of HIV-transmission was associated with the outcome behavior (p = 0.03): those who reported sexual-transmission risks of heterosexual or lesbian sex, or IV needle use, were less likely to report multiple SPs with inconsistent consistent condom use compared to the transmission risk of MSM (β = −0.81 and β = −1.02, respectively), Level of education was a predictor in the model. Compared to those with a high school diploma, participants with had college experience were significantly more likely to have multiple partners and inconsistent condom use (β = 0.71, p = 0.00).
The one self-change process variable significant in the SAT model was self-efficacy for condom use, and this was in a negative direction (β = −0.05, p = 0.00): those with higher scores for condom use self-efficacy were less likely to have multiple SPs with inconsistent condom use. The substance use frequency indicator was a strong predictor in the model as well. Compared to those who were abstinent, frequent substance users were significantly more likely to engage in the high HIV-transmission risk behavior (β = 0.98, p = 0.00). This model predicted twenty-one percent of the variance (pseudo R2 = 0.21).
For comparison, the additional behavioral outcomes of had sex, sex without a condom, and had sex with multiple partners were used as outcome variables in the same regression model procedure (Table 4). Of note, similar patterns were evident with age, gender, education, substance use frequently and HIV transmission risk behaviors. Race ethnicity was significant with having sex, such that African Americans and Asian/Pacific Islanders reported having sex more frequently. Ethnicity was not apparent in the sexual-risk model however. In addition, higher stigma scores were predictive of not having sex, and higher anxiety scores were associated with having sex.
The SAT framework offered by Traube et al. (2011) views condom use as a self-regulated, health protective behavior occurring within an environmental context of social interaction and interdependence. Although SAT does not specify exactly what factors or measures to use for predicting sexual risk behavior, it does suggest pathways to test hypothesized mediators and moderators of risk behavior. The SAT model was fairly robust, but did not explain the impact of all influences in condom use. This approach does provide an exemplar for other researchers to test hypotheses on outcome behaviors using different contextual, self-change and health protective measures gleaned from the scientific literature. As a broad health promotion model, SAT did prove to be practical for exploring HIV-transmission risk behavior.
The findings support some research associated with age and frequency of HIV-transmission risk behaviors. This sample was multiethnic, yet ethnicity was not significant. Therefore, it is important to consider all ethnic groups when addressing sexual risk behavior, and to include probability sampling for making inferences about ethnicity. As is frequently noted, MSM engaged in more transmission risk behavior in this international sample. The significant association between higher education and less self-protective behavior is a unique finding. Further research is needed to explore the association between education level and personalized stigma, as educated persons who contract HIV may be less likely to risk communication about their serostatus. In addition, during this decade, with reduced federal funding for HIV prevention, high schools and universities may be cutting back on HIV-prevention education activities that reach those entering the collegiate arena.
Self-efficacy for condom use was the only self-change construct associated with the high HIV-transmission-risk outcome behavior in the model. None of the other intrapersonal constructs were associated with lower risk behavior, giving additional credence to the importance of self-efficacy in the HIV-positive person’s cognitive base. Coupled with the influence of education, it may be that some PLWH are knowledgeable about the requisite skills for using condoms but lack a sense of efficacy for managing condom use in their social environments. There is a difference between possessing knowledge and skills, and being able to use condoms under challenging circumstances (Bandura 1994). Using condoms consistently requires skillsets for problem-solving, affect regulation, and harnessing motivation.
Despite variations in measuring condom use efficacy (Kalichman et al. 2001), perceptions of efficaciousness appear to influence one’s ability to negotiate condoms in a variety of contexts (Illa et al. 2008; Kalichman et al. 2001; Minor et al. 2009). These findings strengthen support for HIV transmission-risk reduction interventions focused on self-efficacy beliefs.
Frequent drug users engaged in sexual risk behavior significantly more than those categorized as drug abstinent. Alcohol and/or illicit drug use before sex may alter cognitive abilities needed for making sound decisions about condom use or for refusing unsafe sex. Sullivan (2009) reported that frequency of crack use was associated with less condom use in a sample of PLWH who were mostly men who had sex with men. Kalichman and Nachimson (1999) also reported that nearly one-quarter of women who had at least one occasion of unprotected sex without disclosing serostatus did not use condoms after having alcohol and/or other drugs before sex.
The sample size was robust, and participants self-reported about their sexual risk and other behaviors. The number of persons who reported having multiple sexual partners without consistent condom use was comparatively small, limiting the ability to generalize findings, especially to women. To manage missing data, categories used for analyses included, engaged in the behavior or, did not engage or did not report. It may be that some participants who did not report their risk behaviors actually engaged in them. However, with the inclusion of other transmission-risk behaviors (sex without condoms, multiple sexual partners), comparative analyses by SAT domains were robust. While the sample was representative of the general distribution of HIV/AIDS cases in the U.S. and Puerto Rico by gender and ethnicity, fewer male participants reported having sex with a male (48.4%), compared to the rate of MSM transmission risk (61.0%) reported in larger U.S. samples (CDC 2014). It may be that MSM were underrepresented in our sample or that the variable used to identify MSM was not sufficiently robust. The study design did not allow for in-depth analyses of relationships with sex partners or partner serostatus. This factors have been identified as important in HIV transmission risk research.
The HIV/AIDS epidemic continues, as evidenced by the recent outbreak in Indiana that has now involved 188 confirmed cases of HIV over an eight-month period. While this outbreak was fueled by IV drug use initially, HIV prevention efforts have expanded to reach travelers and truck drivers, with a key message to avoid risky sexual behaviors (Indiana State Department of Health 2015).
Most HIV infections occur through sexual contact among partners who may be unaware of their HIV status. Nurses are in key positions to address sexual and drug use behaviors that put clients at high risk for HIV. This paper provides a theoretical framework for nurses, health educators and researchers to use as a guide to formulate ideas about what factors are influencing the sexual transmission of HIV. This model can undergo continued testing, to identify cultural, environmental and interpersonal factors influencing the sexual transmission of HIV across the world.
SA theorists assert that in order to understand risk behavior, one must focus on the factors that influence social interactions, the context in which interactions take place, and the social norms that regulate such actions. The testing of this sexual risk behavior model raises the possibility of using SAT to frame a longitudinal group-based intervention with temporal indicators, to address self-efficacy beliefs about condom use among persons living with HIV/AIDS, who are frequent substance users. Questions may be answered about the mediating effect of group support or about problem-solving approaches to curb sexual risk-taking behavior. Using structural equation modeling would ensure that temporal causality can be inferred (Traube et al. 2011). SAT is useful as it is informative for health care providers and can be used to develop interventions for addressing other transmission risk behaviors including non disclosure of serostatus to SPs. In this way, additional high-risk behaviors for the seropositive client can be addressed (Ogden, 2003). Health care personnel need to routinely discuss sexual transmission risk behaviors with seropositive clients, especially with younger, educated men who have sex with men. Interventions that offer strategies that can enhance behavioral intentions to use condoms, tailored specifically to young, educated men that focus on strengthening self-efficacy beliefs for condom use are needed.
Kathleen M. Sullivan, University of Hawaii at Manoa School of Nursing and Dental Hygiene, Honolulu, Hawaii, USA.
Carol Dawson Rose, University of California San Francisco School of Nursing, San Francisco, California, USA.
J. Craig Phillips, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada.
William L. Holzemer, Rutgers State University, College of Nursing, Newark, New Jersey, USA.
Allison R. Webel, Case Western Reserve University School of Nursing, Cleveland, Ohio, USA.
Patricia Nicholas, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, USA.
Inge B. Corless, Massachusetts General Hospital of Health Professions, Boston, Massachusetts, USA.
Kenn Kirksey, Nursing Strategic Initiative Harris Health System, Houston, Texas, USA.
Lucilee Sanzero Eller, Rutgers State university, College of nursing, Newark, New Jersey, USA.
Joachim Voss, Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA.
Lynda Tyer-Viola, Nursing, Pavilion for Women, Texas Children’s Hospital, Houston, Texas, USA.
Carmen Portillo, University of California San Francisco School of Nursing, San Francisco, California, USA.
Mallory O. Johnson, University of California San Francisco School of Nursing, San Francisco, California, USA.
Mallory O. Johnson, University of California San Francisco School of nursing, San Francisco, California, USA.
John Brion, Ohio State University College of Nursing, Columbus, Ohio, USA.
Elizabeth Sefcik, Texas A & M University-Corpus Christi, Corpus Christi Texas, USA.
Kathleen Nokes, Hunter College, CUNY School of Nursing, New York, New York, USA.
Paula Reid, University of North Carolina at Wilmington, Wilmington, North Carolina, USA.
Marta Rivero-Mendez, University of Puerto Rico, San Juan, Puerto Rico.
Wei-Ti Chen, Yale University School of Nursing, New Haven, Connecticut, USA.