Nursing (13:30 ～16:00 Lecture Room 1)
Session chairs: Prof. Makoto Hirai
Prof. Midori Asano

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Health Status and Health Care Utilization by Marriage-based Women Immigrants in
Korea and Policy Directions: Focus on Mental HealthYang-Heui Ahn1)
1) Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea
providers. Cultural competence including cultural behaviour
and cultural sensitivity was measured using the CulturalCompetence Scale. Scores on cultural behaviour for Public
Health Nurses were lower than for care providers at multicultural family centres. However scores for cultural sensitivity
were not significantly different between the two groups. Public
Health Nurses have no educational experience on culture incaring for multi-cultural families.
Acculturation, mental health status, and health careutilization by marriage-based immigrant women: Demographic
characteristics of marriage-based immigrant women were as
follows. The average age of the first marriage for immigrant
women was older compared to Korean women (33.3 years ofage for immigrant women, 28.7 for Korean women). The
average age difference between immigrant women and theirpartners was 9.9 years, while for Korean couples it was 2.7. In
terms of nationality, immigrant women in their twenties at thefirst marriage came from Vietnam or Cambodia. The averageage difference between them and their partners was 17~18 years.
Most immigrant women were high school graduates, but 2030% of women coming from Vietnam or Cambodia had lessthan elementary school graduation. Regarding length ofresidence, 90% of women coming from Vietnam or Cambodia
had under 5 years and 21.5% of immigrant women’s household
monthly income was under 1,000,000won (about 73,800 ￥).
Medical aid benefits were received by 7.9% of immigrant
women, which is higher than the rate for Korean people (3.7%).
Regarding of their acculturation, the greatest difficulty waslanguage difference. The overall level of acculturation stress
was moderate, and cultural shock had the highest score. Taking
their health into account, 52.1%~53.8% of the women had aperceived general health status as good which is higher than the
38.7%, rate for Korean women who are over 19 years of age.
The prevalence rate for depression was 26.5%~40.6%, also
higher than the 18.9%, prevalence rate of depression among
Korean women of the same age. The rate of alcohol
consumption and smoking was lower than for Korean womenof this age. The rate of visits to clinics or hospitals when theyfelt ill was 73.3~78.6%, while to Public Health Centres was
3.3~8.7%.

Introduction
One of the challenges of the 21st century is providing
care to increasingly multicultural societies. Foreigners living
in Korea have increased since 1990s. As of December 31,
2009, 2.4% (1,268,477 persons) of the total Korean
population were foreigners. Of importance is the rate ofincrease every year. Korean society is becoming a
multicultural society. The rate of international marriage
increased in 2005 compared to 2000, but the number ofinternational marriages decreased in 2006 compared to 2005.
However it has stood at over 10% of total marriages.
Marriage-based women make up 75.5% of couples, whichmeans there are 3 times more foreign women than men ininterracial marriages. Most come from China, Vietnam,
Philippines. The Ministry of Justice and the Ministry of
Gender Equality and Family have a central part in making
policies to support marriage-based immigrants. Various
services including Korean language, culture, and otherservices for marriage-based immigrants have been delivered
through multi-cultural family centres based on the“Multicultural Families Support Act”. However health carepolicies for these women are relatively scarce. This everincreasing multicultural population in Korea poses a
significant challenge to nurses offering individualized care to
their clients. The author reviewed articles and reports related
to health status, behaviours, and health care service
utilization by marriage-based immigrant women in Korea,
and proposed policy directions.
Conceptual framework and Methods
Conceptual framework of this research: 1) National
policies and the health care system related to marriage-based
immigrants; 2) cultural competence of nurses; 3) cultural
adaptation and mental health of marriage-based immigrant
women were reviewed based on health determinants of WHO(2005), and behavioural model of Anderson (2008).
Methods: Narrative review was done through 3 nationwide reports and 10 research studies published since 2005.
Results

National policies and health care system related tomarriage-based immigrants: In 2006 the government
instituted a plan consisting of multicultural policies for
immigrants to facilitate integration into their communities.
First 38 Marriage Immigrant and Family Support Centres
were established across the country in 2007, and increased to
171 centres as of 2010. The name was changed tomulticultural family support centres according to the“Multicultural Families Support Act [MFSA]” which wasenacted on March 21, 2008 by the Ministry of Justice.
Maternal and child care are delivered for immigrant womenand their children based on MFSA. Examples are provisionof helpers after delivery, health screening, and interpreters
for health examinations, and medical expenses when awoman delivers a premature baby. These services aresupported by the Public Health Centres (PHCs) in 2010.
Cultural competence of nurses: There was only one
research study on cultural competencies of nurses and care

Policy directions
Based on these results, four policy directions are proposed.
A health care system integrated with language, culture, andhealth literacy is needed: Language is a body of words andsystems of meaning for the use of the words that is common to apeople who are of the same cultural tradition or nation. Limited
Korean proficiency is to be restricted in the ability to read,
speak, write, or understand Korean, so that language difference
can cause difficulty in interrelationships among people. The
language differences themselves are barriers to effective
communication. The inability to communicate with a healthcare provider not only limits access to health care but also
affects the quality of medical care received and appropriatenessof follow-up. Culture refers to the learned, shared andtransmitted knowledge of values, beliefs and life ways of aparticular ethnic group that are generally transmitted intergenerationally and influence thinking, decisions and actions in

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patterns or in certain ways (Leininger, 1991). This pattern ofbeliefs influences how symptoms are recognized and how
they are interpreted and affects how and when health services
are sought. The level of acculturation results in differences in
the use of health care services. One’s culture affects one’s
understanding of a word or sentence and even one’s
perception of the world. Cultural differences, which are often
associated with language differences, are barriers tocommunication with health care providers. Health literacy isdefined as the degree to which individuals have the capacity
to obtain, process, and understand basic health informationand services needed to make appropriate health caredecisions (IOM, 2004). Language and culture provide theexperiential context for comprehension of health information.
The culturally bound beliefs, values, and preferences aperson holds influence how a person interprets health careinformation. Knowing about a client’s language and culture
is a key to assessing the health literacy of the client in a given
situation. Reducing unnecessary diagnostic testing or
inappropriate use of services by providing culturally andlinguistically appropriate care through improvements inhealth literacy leads to efficiency of care. Therefore a healthcare system integrated with culture and linguistics and giving
consideration to health literacy is necessary for quality ofcare and improvement in the health of immigrant women.
Development of national standards on culturally andlinguistically appropriate services & in-service education on
culturally competent health care for public health nurses(PHNs): Cultural competence is important considering PHNs
diverse cultural backgrounds. PHNs often serve as advocatesfor multicultural families through health promotion
interventions and community-based disease control andprevention activities. Being culturally competent allows
PHNs to more effectively engage in practice, advocacy
activities, and to decrease of health disparities. Nurses areaccountable for considering cultural differences whendeveloping care approaches specific to these multicultural
individuals and families. Cultural awareness reflects
knowledge of the differences among individuals and families.
Cultural sensitivity includes one’s attitudes towards others
and one’s openness to knowledge within multiple culturaldimensions. Cultural competence includes actions taken in
response to cultural awareness and sensitivity. It involves theability of individualized care for multicultural women’s
health. Therefore, local and national public health caresystems have to be mandated to provide culturally andlinguistically appropriate services through the developmentof national standards. PHNs and other hospital nurses need to
be offered in-service education programs on culturalcompetency skills. Furthermore, nursing education needs toinclude trans-cultural nursing in the curriculum. The
curriculum in trans-cultural nursing should teach theknowledge and skills needed to provide culturally competentnursing care.
Development of an assessment instrument for high-risk
immigrant women & provision of individualized intervention
programs: The development of an accurate assessment
instrument for immigrant women within the community isessential to culturally competent care. An assessment
instrument needs to develop to discriminate primarily what is
high-risk or not. The instrument including language, culture
and health literacy and should be valid and reliable. Basedon the literature review, immigrant women’s health andhealth behaviour were found to differ by demographic
characteristics, nationality, length of stay in Korea, Korean

language proficiency, and the level of acculturation. Therefore
individualized care is needed.
Vitalizing functions of the Public Health Centres (PHCs):
PHCs provide primary health care. This care is very importantfor immigrant women. Resolution of the three policies above
must precede providing cultural and linguistic competent carewith health literacy at PHCs. Health care of marriage-based
immigrant women is needed at PHCs including care from thetime of entry into Korea, and by life cycle, and according tolevel of acculturation. PHCs need to play a key role with the
network of multi-cultural family centres and other community
resources to enhance the health of these women.
Conclusions
In an increasingly multilingual, multicultural society,providing high-quality health care requires overcoming barriers
such as language, culture, and low health literacy. For the
implementation of high-quality health care practices, there isneed for redesign in the health care delivery system. The
government should also support an integrated health caresystem that is effective, reliable, and sustainable.
References[1]Yang OK, & Kim, YS. A study on the effects ofdepressiveness among foreign wives through marriage
migration. Mental Health & Social Work 2007; 26: 79-110.
[2]Yang SJ, Kim JA, Kim SN, Choi HY, Park CS, & Dan HJ.
Health Concept, Health Status and Health Service Utilizationof Marital Immigrant Women in Urban and Rural Areas in
Korea. Ministry of Health and Welfare ㆍ Ewha Womans
University: 2009.
[3]Park, HS, Bae, KE, Kim, DH, Yoon, YR. A survey on healthrelated status of marriage-based immigrant women. Korean J
Fundamentals Nurs 2008; 15: 80-88.
[4]WHO Europe, European Health Report 2005 - Public Health
Action for Healthier Children and Population, 2005.
[5]Anderson, RM. National health surveys and the behavioral
model of health services use. Medi Care 2008; 46: 647-653.
[6]Ahn, YH, Park, MJ, & Lee EJ. Development of Family
Health Guide for Service Providers. Research Institute for
Gangwon ㆍ Yonsei University: 2009.
[7]Seol, DH, Kim, YT, Kim YM, Yoon HS, Lee HK, Lim KT etal. A Survey on Marriage-based Immigrant Women in Korea
and Policy measures. Ministry of Health and Welfare: 2005.
[8]Kim, SK, Kim, YK, Cho, AJ, Kim, HR, Lee, HK, Seol, DH
et al.. A Nation-wide Survey on Multi-cultural Family.
Ministry of Health and Welfare ㆍ Ministry ofJustice ㆍ Ministry of Gender & Equality ㆍ Korea Institutefor Health and Social Affairs: 2010.
[9]Kim, HJ. A study of social support, the demand for healtheducation, and quality of life for married female immigrants.
Korean J Women Health Nurs 2008; 14: 5-11.
[10]Jeong NO. A prediction model of health-promoting
behavior in married immigrant women[Unpublisheddoctoral dissertation]. Jeonju: Jeonbuk National University;
2008.
[11]Noh, HN. A study on acculturative stress of the Chinese
women who got married to Korean men and sellted down in
Korea[Unpublished master's thesis]. Seoul; Ewha Womans
University; 2007.
[12]Korean Center for Disease Control and Promotion. 2008
National Health Statistics: The 4th national survey on
health and nutrition. Seoul: Author: 2008.
Author address

E-Mail: ahn57@yonsei.ac.kr

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Association of Underweight with Low Lymphocyte Count and Prealbumin
as Indicator of Malnutrition in Japanese Women
T.Nishida1), Y.Okamura2), H.Sakakibara2)
1) Aichi Health Plaza Comprehensive Health Science Center2) Department of Nursing, Nagoya University Graduate School of Medicine

Introduction
Results
Underweight women in their 20s and 30s appear healthy, but
may have potential health problems. Previously, we reported
that severely underweight Japanese women in their 20s and 30s
tended to have decreased lymphocyte counts.[1] Thelymphocyte count is known to decrease in a poor nutritional
state, due especially to protein-energy malnutrition, and it isregarded as a nutritional state indicator.[2] Hence, lowlymphocyte counts in underweight women might reflect theirpotential malnutrition. In our previous study, we only examined
lymphocyte counts, not albumin or prealbumin. All three are
regarded as indicators of malnutrition,[2] and are used as
popular markers of nutrition screening for hospital inpatients.
The aim of the present study was to investigate the healthproblems of Japanese underweight women in their 20s and 30s
who underwent a health check-up by measuring albumin,
prealbumin and lymphocyte count as indicators of theirnutritional status.
Methods
Design and sample
A cross-sectional study was conducted with population-based
samples. The subjects were recruited from females aged 18-39
years who participated in an annual health check-up from
November 6 to 27, 2008, for residents of a city in Aichi
prefecture, Japan. Women who were under medical treatment,
pregnant or currently breast-feeding were excluded from thepresent analysis. This left 912 participants (mean age (SD):33.6 (4.0) years, range 19-39 years) eligible for the present
analysis.
Measurements
The health check-up included a questionnaire about clinicalhistory and lifestyle, body height and weight measurements,
and blood examinations. BMI (kg/m2) was calculated as weightin kilograms divided by the square of height in meters. The
self-administered questionnaire included questions on smoking,drinking habits, pregnancy, breast-feeding and weight change.
Data analysis
BMI was categorized as underweight (BMI <18.5 kg/m2),
normal weight (18.5≤ BMI <25 kg/m2) and obese (BMI ≥25
kg/m2). Weight change in the last 3 months was categorized asweight loss (of 1 kg and over), no change (within 1 kg) andweight gain (of 1 kg and over). Nutritional assessments weredone on the basis of the cut-off values: albumin of <3.5 g/dl,
prealbumin of <20 mg/dl and a lymphocyte count of <1500 /μl.
This study was approved by the ethics committee of the
Nagoya University School of Medicine.

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The prevalence of underweight (BMI <18.5 kg/m2) was 23.0%(n = 210); normal weight (18.5≤ BMI <25 kg/m2) was 68.3% (n= 623); and obese (BMI ≥ 25 kg/m2) was 8.7% (n = 79). As forblood examinations, the leukocyte (p < 0.001), neutrophil (p =0.001), monocyte (p = 0.004), and lymphocyte counts (p <0.001) declined with a decrease in BMI. Serum prealbumin also
decreased with lower BMI (p < 0.001). The prevalence of low
lymphocyte counts of less than 1500 /μl was higher in theunderweight group (p = 0.001). The prevalence of a low
prealbumin level of less than 20 mg/dl tended to be greater
among the underweight group, though not significantly (p =0.098). Serum albumin increased with lower BMI (p = 0.009),
but no one displayed a low albumin level of less than 3.5 g/dl.
Serum total protein did not differ among the BMI groups.
In a comparison among the weight change groups, BMI
tended to be lower in the weight loss group (p < 0.001).
Lymphocyte counts (p < 0.001) and serum prealbumin (p <0.001) were lower in the weight loss group, while serum
albumin was higher in the weight loss group (p = 0.012). The
prevalence of low prealbumin of less than 20 mg/dl increased
with weight loss (p = 0.038), while that of low lymphocyte
counts of less than 1500 /μl did not differ among the weightchange groups.
The possible association of being underweight and weightloss with a low lymphocyte count of less than 1500/μl or low
prealbumin of less than 20 mg/dl was examined by multivariate
logistic regression analysis after adjusting for age, smoking anddrinking habits. The multivariate logistic regression analysis
showed an association of low lymphocyte counts (< 1500/μl)
with being underweight (odds ratio (OR) 1.96, 95% confidence
interval (CI) 1.35−2.83), but not with weight loss in the last 3
months. On the other hand, low prealbumin (<20 mg/dl) was
associated with weight loss (OR 1.42, 95%CI 1.00−2.02), but
not with being underweight.
In relation to the BMI and weight loss groups, theprevalence of low lymphocyte counts and that of low
prealbumin levels were examined among 647 subjects who hadneither smoking nor drinking habits to exclude the influence ofthe two habits (Table 1). Low lymphocyte counts (<1500 /μl)
were most frequently found in 7 (35%) in the underweight plus
weight loss groups (n = 20). Further, 4 (50.0%) had low
lymphocyte counts (<1500 /μl) among 8 underweight women
who lost weight of 2 kg or more in the last 3 months. The
prevalence of low lymphocyte counts tended to be higher withlower BMI in the weight loss subjects (p = 0.077) or those
without weight change (p = 0.039). On the other hand, theprevalence of low prealbumin (<20 mg/dl) was not at its
highest in the underweight plus weight loss groups. The
prevalence tended to be higher in the weight loss group in thenormal weight (p = 0.010) and obese subjects (p = 0.023).

2
Discussion
References
The present study showed that underweight women were likely
to have lower lymphocyte counts. The prevalence of a low
lymphocyte count (<1500 /μl) tended to be higher in theunderweight subjects. In addition, the prevalence was higher by
35% among underweight women who lost weight of 1 kg or
more in the past three months, and higher by 50% among those
who lost weight of over 2 kg. Protein-energy malnutrition(PEM) is known to decrease lymphocyte counts, andlymphocyte counts are used as an indicator of PEM.[2] Thesefindings suggested that underweight women in their 20s and
30s can be at risk for low lymphocyte count or potential
malnutrition. The risk for malnutrition is thought to beparticularly high in underweight women who have lost weight
recently.
In our present study, albumin and prealbumin showed noclear association with being underweight. It may be difficult toassess malnutrition by albumin and prealbumin. Earlier studies
have reported that concentrations of albumin and prealbumin
were within the normal range even in patients with anorexia
nervosa.[3,4] Other studies have also demonstrated that albumin
and prealbumin concentrations did not differ between patientswith anorexia nervosa and the controls.[5] The present study
suggested that lymphocyte counts could serve as a moresensitive indicator of nutritional status in underweight womenthan either serum prealbumin or albumin. This manuscript has
been published in the Journal of Women’s Health.[6][1] Nishida T, Sakakibara H. Low lymphocyte count inunderweight Japanese women. Environ Health Prevent Med
2008;13:345-348.
[2] Omran ML, Morley JE. Assessment of protein energy
malnutrition in older persons, Part II: Laboratory evaluation.
Nutrition 2000;16:131-140.
[3] Myron Johnson A, Merlini G, Sheldon J, et al. Clinicalindications for plasma protein assays: transthyretin(prealbumin) in inflammation and malnutrition. Clin Chem
Lab Med 2007;45:419-426.
[4] Kiriike N, Nagata T, Nakanishi S, et al. Blood biochemical
abnormalities of patients with anorexia nervosa and bulimia.
Jap J Clin Psychiatry 1990;19:609-616.
[5] Nova E, Lopez-Vidriero I, Varela P, et al. Indicators ofnutritional status in restricting-type anorexia nervosa
patients: a 1-year follow-up study. Clin Nutr
2004;23:1353-1359.
[6] Nishida T, Sakakibara H. Association between underweight
and low lymphocyte count as an indicator of malnutrition in
Japanese women. J Womens Health (Larchmt)
2010;19:1377-1383.
Author address
E-mail: sbara@met.nagoya-u.ac.jp

TABLE 1. FREQUENCY (%) OF LOW LYMPHOCYTE COUNT OR LOW PREALBUMIN ACCORDING TO
UNDERWEIGHT AND WEIGHT CHANGE GROUPS
Underweightn%Normal weight
n
%

n

Obese
%

pa

Low lymphocyte
Normal lymphocyte

7
13

35.0
65.0

7
47

13.0
87.0

1
5

16.7
83.3

0.077

Low lymphocyte
Normal lymphocyte

20
94

17.5
82.5

43
261

14.1
85.9

1
38

2.6
97.4

0.039

Low lymphocyte
Normal lymphocyte
pb

2
10

16.7
83.3

14
71

16.5
83.5

0
13

0.0
100.0
0.113

0.226

Low prealbumin
Normal prealbumin

4
16

20.0
80.0

12
42

22.2
77.8

2
4

33.3
66.7

0.573

Low prealbumin
Normal prealbumin

20
94

17.5
82.5

57
247

18.8
81.3

2
37

5.1
94.9

0.262

Low prealbumin
Normal prealbumin
pb

2
10

16.7
83.3

6
79

7.1
92.9

0
13

0.0
100.0
0.023

0.112

Weight loss

No change

Weight gain

0.129

0.540

Weight loss

No change

Weight gain

0.790

0.010

647 subjects with no habits of smoking and alcohol consumption were used for analysis.
Underweight (BMI <18.5 kg/m2), Normal (18.5≤ BMI <25 kg/m2), Obese (BMI ≥25 kg/m2). Weight change was classified
according to weight changes in the previous three months. Low lymphocyte (<1500 /μl), Normal lymphocyte (≥1500 /μl). Low
prealbumin (<20 mg/dl), Normal prealbumin (≥20 mg/dl).
ap values by chi-square for trend between indicators of malnutrition with BMI in each weight change group.
b
p values by chi-square for trend between indicators of malnutrition with weight changes in each BMI group.

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Comparison of Salivary Cortisol, Heart Rate, and Oxygen Saturation Between Early
Skin-to-Skin Contact Methods with Different Initiation and Duration Times in Healthy,
Full-Term Infants
Y. Takahashi1), K. Tamakoshi1)1) Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
Study 2: To assess whether or not the difference in the
duration of SSC influences salivary cortisol levels over the first
2 hours after birth.

Introduction
Skin-to-skin contact (SSC) is a well-known caring
method to facilitate the neurobehavioral self-regulatory
responses of the infant after delivery. However, there are few
studies that compare the physiological and biologicalefficacies between different early skin to skin contact (SSC)
methods postbirth. The aim of the present study was toinvestigate how two different SSC methods based on
initiation time and duration influenced indicators of stress asmeasured by salivary cortisol besides time to stability of HR
and SpO2 among healthy full-term infants.

Figure 1 Flow of the participants though the study anddate collection.
Newborn infants whose parents
was informed and give theconsent （n＝147）
Birth SSC hospital: n=72
Very early SSC hospital: n=75

EXCLUDED(Total=39)
1.Maternal exclusion• Not spontaneous vaginal delivery• General anesthesia during labor and birthMaterials and Methods
Subjects: We conducted an observational study of 147
consecutive newborn infants who were born spontaneously at
two maternity hospitals in Aichi Prefecture, Japan, fromJanuary to October in 2009. The subjects were healthy fullterm infants who were selected according to the criteria
below: Maternal inclusion criteria were spontaneous vaginal
delivery, singleton full-term infant, and uncomplicatedpregnancy and delivery courses. Maternal exclusion criteria
were dysfunctional labor, dystocia, sign of fetal distressduring labor, general anesthesia during delivery, multiple
birth, and cesarean section. In addition, infants had to behealthy and full term. Infant exclusion criteria were any
congenital anomaly, and obvious birth asphyxia as assessedby either 1- or 5-minute’ apgar of seven or less. Furthermore,
the infants for whom the salivary cortisol levels wereobtained at 1min, 60 min, and 120 min were eligible for thisstudy. Finally, the current analysis was restricted to 79
healthy full-term infants, 68 for whom data were obtained on
both heart rate and oxygen saturation(figure1). This study
protocol was approved by the Ethics Review Committee of
the Nagoya University School of Medicine, Nagoya, Japan.
Salivary Cortisol:Saliva specimens were collected a totalof 3 times; at 1 min after checking 1-min apgar score, and 60
min and 120 min after birth, respectively. Saliva wascollected from infants using the Sorbette (Salimetrics, LLC,
Pennsylvania, USA). After collection, the saliva was stored
at – 83°C. Salivary cortisol concentration was determinedusing a commercial high sensitivity EIA kit (Salimetrics,
LLC, Pennsylvania, USA).
Heart Rate and Oxygen Saturation: Pulse oximetry
measurements were carried out using a NELLCOR
Oxisensor N-25 and a NELLCOR™ OxiMax™ N-600™
Pulse Oximeter (Covidien-Nellcor and Puritan Bennett,
Boulder, USA). We placed a pulse oximetry probe over the
newborn’s right sole as soon as possible after birth. The pulse
oximeter recorded arterial SpO2 and HR every 10 seconds for
120 min after birth.
Study 1:To determine whether or not the difference in theinitiation time of SSC influences the time to stability of HR
and SpO2 for almost 30 min after birth. The time to stabilityof HR and SpO2 were defined as the first of 3 consecutive
HR readings of 120-160 beats per minute (bpm) and SpO2
reading of 96% =<, respectively. The first time of 3
consecutive SpO2 reading of 92% =< was also evaluated.

n=10
n= 7

2. Infant exclusion• Not full-term infantsn= 2• Birth asphyxia
n= 8(include seven or less points of Apgar score at either 1 or 5
minutes)• Acidosis (by an umbilical artery)n= 2• Low birth weight infants (< 2,500 g)
n=10
Assessed for eligibility(n=108)Birth SSC hospital: n=58
Very Early SSC hospital: n=50
• No SSC (Their mothers did not want to do)n= 5• Not all of the saliva specimens at 3 timesn= 9• Not enough Saliva volume to measure cortisol

n=15

Final study subjects: n=79
• Birth SSC hospital: n=41• Very Early SSC hospital: n=38
• Not obtain both heart rate andoxygen saturation n=11

DATA AVAILABLE FOR STUDY I: n=68

DATA AVAILABLE FOR STUDY II: n=79

• Birth SSC• Very Early SSC• SSC for 60 min or less
• SSC for more than 60 min

n=32
n=36

n=18
n=61

Data analysis: In study 1, study infants were divided into
two groups: those who began SSC 5 min or less (n=32) after
birth and those who did so more than 5 min (n=36) after birth.
In the present study, the former group was defined as 'birth SSC'
and the latter group as 'Very early SSC' based on theclassification of early SSC by Moore et al.2 Kaplan-Meiercurves were generated for time to HR and SpO2 stability. The
difference between groups was assessed with log-rank test. Next,
we used Cox proportional hazard model to relate the time of HR
or SpO2 stability to a number of explanatory variables including
SSC initiation time category, umbilical artery pH, labor
induction, meconium staining, birth weight, and total length offirst-stage and second-stage labor in minutes. The exponent of
the parameter estimate of SSC initiation time category[EXP(parameter estimate)] indicates the efficacy of Birth SSC
group compared with the reference category (Very early SSC
group). Additionally, mean HRs were calculated at 1-min
intervals from 3 to 30 min after birth.
In Study 2, we divided the subjects into two groups: those
who underwent SSC for 60 min or less (n=18) and those who
did so for more than 60 min (n=61). As we measured salivary
cortisol levels a total of 3 times for 120 min after birth, theN-3

general linear model (GLM) in SPSS that is used in repeatedmeasures designs (two-way repeated measures ANOVA) wasused to compare the effect on salivary cortisol levels between
the two groups and calculate each mean cortisol level 3 timesby 2 groups while adjusting for the initiation time of SSC,
umbilical artery pH, labor induction, meconium staining,birth weight, and total length of first-stage and second-stage
labor in minutes. Data were analyzed using the SPSS
statistical package for Windows Version 17.0 (SPSS,
Chicago, USA). Differences were considered significant
when P<0.05 for the two tails.
Results
HRs showed a lower tendency among the birth SSC
group than the very early SSC group. There were significant
differences at 5, 10, 15, and 20 min (P<0.05, P<0.01, P<0.01,
P<0.05, respectively). Kaplan–Meier analysis showed asignificant difference in the cumulative probability of HR
stability of 120-160 bpm between the subgroups (P<0.01). In
Cox model analysis, the birth SSC group showed 2.52 times
the efficacy of HR stability compared with the very early
SSC group [EXP(0.925)=2.52 (95% CI: 1.41-4.51), P<0.02].
Also, the cumulative probability of the SpO2 stability of 92%=< and 96% =< using Kaplan-Meier analysis. It did notshow any significant difference in cumulative probabilities of
either 92% =< nor 96% =< between the subgroups (P=0.69
and 0.39, respectively). Cox model analysis also showed nosignificant associations between initiation time of SSC andSpO2 stability [SpO2 stability of 92% =< as dependent
variable; EXP (parameter estimate)=EXP(0.062)=1.06 (95%
confidence interval: 0.609-1.86), P=0.872 and SpO2 stabilityof 96% =< as dependent variable; EXP(0.111)=1.12 (95%
CI: 0.652-1.92), P=0.652]. Crude means (standard error: SE)of salivary cortisol were 6.10 (0.74) μg/dl at 1 min, 4.72
(0.50) μg/dl at 60 min, and 2.71 (0.41) μg/dl at 120 min in
the infants who underwent SSC for 60 min or less, and 6.29
(0.40) μg/dl at 1 min, 4.04 (0.27) μg/dl at 60 min, and 2.09
(0.22) μg/dl at 120 min in those who did so for more than 60
min. The cortisol level for 1 min was not significantly
different between the subgroups (P=0.824). Salivary cortisol
levels showed decreasing trends in both groups and no
significant difference between two groups (P=0.429). After
multivariate adjustment, the adjusted means (SE) were 5.03
(0.46) μg/dl at 60 min and 2.71 (0.40) μg/dl at 120 min
among the infants who underwent SSC for 60 min or less,and 3.94 (0.24) μg/dl at 60 min, and 2.08 (0.21) μg/dl at 120
min among those who did so for more than 60 min. SSC
continuing for more than 60 min significantly decreased
salivary cortisol levels between 60 and 120 min after birthcompared with SSC for 60 min or less (P<0.05).
Discussion
In our study of healthy full-term infants, we found thatbirth SSC lead to the stability of HR earlier than very early
SSC. All of measured body temperatures postbirth kept innormal range though they were significantly lower in thebirth SSC group than the very early SSC group. In addition,
SSC continuing for 60=< min significantly decreased
salivary cortisol levels as a marker for stress at 2 hours
postbirth compared with SSC for only <60 min. The present
study proposed further evidences of early SSC for full-term
infants.
Most of the studies also compared the infants with SSC
with control infants who were separated from their mothers.
To our knowledge, there were only a few randomized control
studies that compared behavioral and physiological change of
infants or mothers between dyads with different initiation

times and/or duration of SSC. In the study by Christensson etal.1, 44 healthy full-term infants were observed during the first
90 min after birth in terms of duration of crying when infants
were cared with: 1) 76-85 min of SSC with mother. 2) In a cot
for the first 45 min of 90 min observation period and then SSC
with the mother for 45 min. 3) In a cot for 76-85 min. The
cumulative amount of crying during the first 90 min after birth
was significantly less in the SSC group than in the mixed
cot/SSC group. The findings of this previous study seemed
likely to support ours. In the previous studies examining theefficacy of SSC during the early period after birth, infant
temperature, HR, respiratory rate, and blood glucose have beenused as study outcomes. So we paid due attention to salivary
cortisol. We found a significant difference in the effects of SSC
on salivary cortisol immediately after birth between infants with
SSC of 60 min or less and those with more than 60 min. It isdifficult to explain the unitary mechanism underlying thevarious efficacies of SSC. SSC is suggested to facilitate theneurobehavioral self-regulatory responses of the infants who
persist in more labile imbalance and fluctuation of autonomic,
motor, state, and attention/interaction subsystem. Our findings
are supposed to be due to the postbirth development of selfregulation of each subsystem by SSC. Self-regulation isconsidered as infant adaptation to various internal and external
stimuli and to unstable situations, and is in great demand
immediately after delivery. Early SSC may be a ‘nature way’ ofantagonizing the ‘stress of being bone’ like the other mammals.
Therefore, ‘When should SSC start after birth?’ and ‘How longshould SSC be underwent?’ are the important problems inestablishing the effective SSC. Additionally, it is also necessary
to establish the safety SSC method.
There are two limitations in our study. One limitation wasthat our study was observational. Thus, subjects must be
randomized to confirm our results even enough, though thecharacteristics of SSC groups were almost comparable andmultivariate adjustment was performed. Another limitationarises from the fact that healthy and full-term infants were thesubjects of our study. Hence, our results may not apply topreterm infants and infants with any complication.
Conclusions
Birth SSC lead to the stability of HR earlier than very early
SSC. All of measured body temperatures postbirth kept innormal range though they were significantly lower in the birth
SSC group than the very early SSC group. In addition, SSC
continuing for 60=< min significantly decreased salivary
cortisol levels as a marker for stress at 2 hours postbirthcompared with SSC for only <60 min.
References[1] Christensson K, Cabrera T, Christensson E,et al. Separation
distress call in the human neonate in the absence of maternal
body contact. Acta Paediatr 1995;84:468-473.
[2] Moore ER, Anderson GC. Bergman N. Early skin-to-skincontact for mothers and their healthy newborn infants.
Cochrane Datebase of Systematic Reviews 2007;Issue 3.

Author address

E-Mail: takahashi.yuki@a.mbox.nagoya-u.ac.jp

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Evidence-Based Nursing Strategy for Acute Ischemic Stroke Patients Managementin the Emergency Department
Ji-Eun Baek1)
1) Department of Nursing, Yonsei University Wonju College of Medicine, Wonju, Korea

The penumbra consists of potentially salvageable brain cells,
so it is critical that oxygen-saturated blood is provided to thatarea early during a stroke. As little as 2 L/min of supplemental
nasal oxygen can raise oxygen saturation from 90% to morethan 95%, which in turn may improve tissue oxygenation[5]. If
breathing effort is inadequate the patient will require ventilatory
assistance to supply sufficient oxygen to the brain. If a patient isexperiencing a rapid deterioration secondary to increased
intracranial pressure it may be useful to hyperventilate thepatient to lower the partial pressure of carbon dioxide (pCO2).
Carbon dioxide is a potent vasodilator and lowering its
concentration may aid in constriction of the vascularcompartment and rapidly reduce intracranial pressure. However,excessive lowering of pCO2 can lead to increased ischemia. The
goal therefore is to lower pCO2 to 25 mm Hg.
Breathing rate and rhythm is controlled within the brainstemand can be affected by brain swelling. Downward displacementof the brain and brain stem can be caused by edema, increased
blood flow, or blood from a hemorrhage. This can lead toventilatory pattern changes as the body tries to decrease the sizeof the vascular bed by blowing off carbon dioxide. Abnormal
ventilatory patterns and yawning are signs of increasingpressure in the brain and on the vagus nerve(that controls
respiratory muscles) as the nerve is squeezed through theforamen magnum(herniation). A stroke occurring within thearterial blood flow of the brainstem or cerebellum can also leadto respiratory pattern changes. In addition to oxygen saturation,
patients should be monitored for respiratory rate and rhythm.

Introduction
Stroke, a sudden loss of neurologic function resulting
from an acute disruption of blood flow, is the leading causeof long-term disability and the second leading cause of deathin South Korea.
Emergency nurses are often the first health professionals
to come into contact with stroke patients on arrival at
hospital, but their understanding of the basic management of
acute stroke is often limited[1]. An important part of acutestroke management and decreasing stroke-related mortality is
preventing complications within the first 24–48 hours[2].
The purpose of this study was to establish an evidencebased nursing strategy for Emergency Department nurses toaid in understanding basic management and preventing ofcomplications of acute ischemic stroke.
MethodThis study was performed using a methodological design.
Referring to four Stroke Guidelines by the Clinical ResearchCenter For Stroke in South Korea. And the Detailed Nursing
Strategy was obtained through the procedure of critical
literature analysis.
Nursing Strategies: ABCDs of Acute Stroke Management
A IS FOR AIRWAYS
Obstruction or dysfunction of the airway is notuncommon in acute stroke. To ensure that the patient’s
airway is maintained during acute ischemic stroke, nurses
should be prepared to suction, control the airway, andprevent aspiration. Patients unable to handle secretions need
to be intubated to protect the airway. Initially, if the level ofconsciousness is decreased, but the ability to swallow is
intact, the patient may only need an oral or nasal aid tomaintain the airway.
Emergency department nurses are asked frequently togive medications or fluids to a stroke patient. Dysphagia is asign of a potentially dysfunctional airway and an obvious risk
for aspiration. In one study of 30 patients with acute stroke,dysphagia was noted in 57%. These patients had longer
hospital stays, more complications, and a higher rate ofmorbidity[3]. Assessment of swallowing ability should be
carried out according to institutional procedure guidelines.
Following a dysphagia screening protocol, or algorithm, is
recommended as standard practice in the evaluation ofpatients with acute stroke[4]. Should the patient choke, gag,or gasp for breath before or during screening, he or sheshould be kept nothing by mouth (NPO). Brain stem infarcts
increase the risk that the patient will have speech andswallowing difficulty. Patients passing the swallowing screen
can start nutrition early, but reassessment of swallowing is
recommended because symptoms may worsen or fluctuatewith time.

C IS FOR CIRCULATION
The irreversible neurologic deficits of a stroke result whenblood flow to an area of the brain is reduced to approximately
25% of the normal value[6]. This loss of perfusion leads to alack of oxygen and glucose to the cells, resulting in cell death[7].
Cells in the surrounding penumbra may still be viable[8].
Because blood flow in the penumbra is also decreased,
perfusion to this ischemic area needs to be reestablished quickly.
Action taken during this critical early phase of a stroke can
improve or maintain circulation, which allows sufficient oxygenand glucose to reach the neurons in this vulnerable area.
In acute stroke, circulation can be hindered by the increasingmass(eg, from edema) within the skull[9]. A normal response to
the lack of oxygen within the brain is a rise in blood pressure.
Although rising blood pressure can increase perfusion to thebrain for a short time, it may lead to edema, increased
intracranial pressure, and an increase in the size of brain massand potential herniation[10].
Rapidly lowering blood pressure in the ischemic stroke
patient can lead to decreased perfusion of the already stressed
brain cells. Nurses involved in stroke care need to be aware that
cerebral perfusion pressure(the difference between mean arterialpressure and intracranial pressure) should be maintained at alevel above 40 mm Hg to obtain adequate blood flow to brain
tissue. Systolic, diastolic, and mean arterial blood pressure(MAP) will be higher than usual, as MAP below 100 mm Hg
have been shown to correlate with poorer outcomes[11]. The

B IS FOR BREATHING

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exception is in patients who receive rt-PA: blood pressure
will need to be lowered to prevent complications from the
medication during reperfusion.
Classically, in patients with impairment of cerebral
circulation due to a clot, reperfusion is attempted using
fibrinolytic therapy(eg, rt-PA). Nurses should know theinclusion criteria to identify patients for such therapy, as
rapid evaluation for appropriateness and initiation ofadministration of fibrinolytic therapy is critical in preventing
cell death[12]. It is important to remember that there is only a
3-hour window from onset of symptoms in which
intravenous rt-PA can be given, after which the risk of
bleeding increases. Nurses should also facilitate obtaining
appropriate lab tests and a brain CT scan, with the highest
priority placed on rapidly securing the scan. The CT scanmust be completed and results obtained before a patient withsuspected ischemic stroke can be treated with fibrinolytic
therapy. Time is critical, and all members of the stroke careteam need to expedite the process. Communication among
pre-hospital personnel, ED nurses and doctors, and radiology
staff can produce a door-to-CT time of just a few minutes.

quicker implementation of treatment and to effectively treating
this disease as a high-priority emergency. Additionally,
continued monitoring of the ABCDs can lead to earlyrecognition of patient deterioration. Rapid intervention andpreventing poststroke complications are vital when emergency
nursing personnel evaluate stroke.
References[1]Harper JP. Emergency nurses’ knowledge of evidence-based
ischemic stroke care: a pilot study. Journal of Emergency
Nursing. 2007;33( 3):202-207.
[2]Anderson D, Neacy K, Stead L, Koshnick R, Lee J, McRaith
J, Haake B, Robinstein A, Lakshminarayan K, Wallace GJL,
Hunteman T, Metfessel B & Suber S. Health Care
Guideline: Diagnosis and Initial Treatment of Ischemic
Stroke, 5th edn. Institute for Clinical Systems Improvement.
October 2006; Minnesota.
[3]Runions S, Rodrigue N, White C. Practice on an acute stroke
unit after implementation of a decision-making algorithm for
dietary management of dysphagia. J Neurosci Nurs
2004;36:200-207.
[4]Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S,
for the Stroke Practice Improvement Network Investigators.
Formal dysphagia screening protocols prevent pneumonia.
Stroke. 2005;36:1972-1976.
[5]Ali K, Sills S, Roffe C. The effect of different doses ofoxygen administration on oxygen saturation in patients withstroke. Neurocrit Care 2005;3:24-26.
[6]Dohmen C, Bosche B, Graf R, Staub F, Kracht L, Sobesky J,
et al. Prediction of malignant course in MCA infarction by
PET and microdialysis. Stroke. 2003;34:2152-2158.
[7]Aminoff MJ, Greenberg DA, Simon RR. Clinical neurology.
6th ed. New York: McGraw-Hill. 2005;285-319.
[8]Fagan SC, Hess DC. Stroke. In: DiPiro JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM, editors.
Pharmacotherapy: A pathophysiologic approach. 6th ed.
New York: McGraw-Hill. 2005;415-427.
[9]Favad PB, Awad IA. Surgery for intracerebral hemorrhage.
Neurology. 1998;51(3):69-73.
[10]Mattle HP, Kappeler L, Arnold M, Fischer U, Nedeltchev K,
Remonda L, et al. Blood pressure and vessel recanalizationin the first hours after ischemic stroke. Stroke.
2005;36:264-269.
[11]Stead LG, Gilmore RM, Decker WW, Weaver AL, Brown
RD Jr. Initial emergency department blood pressure aspredictor of survival after acute ischemic stroke. Neurology.
2005;65: 1179-1183.
[12]Adams HP Jr, Adams R, Brott T, del Zoppo GJ, Furlan A,
Goldstein LB, et al. Guidelines for the early managementof patients with ischemic stroke: A scientific statementfrom the Stroke Council of the American Stroke
Association. Stroke.2003;34:1056-1083.
[13]Nor AM, McAllister C, Louw SJ, Dyker AG, Davis
M,Jenkinson D, et al. Agreement between ambulanceparamedicand physician-recorded neurological signs with
Face Arm Speech Test (FAST) in acute stroke patients.
Stroke. 2004;35:1355-1359.
[14]Williams LS, Rotich J, Qi R, Fineberg N, Espay A, Bruno
A, et al. Effects of admission hyperglycemia on mortality
and costs in acute ischemic stroke. Neurology. 2002;59:6771.

D IS FOR DISABILITY AND DEXTROSE
Because stroke is a leading cause of long-term disability,
nurses should be able to quickly identify the patient withstroke symptoms. Assessment tools that can quickly identify
the patient at risk for stroke are the Face Arm Speech Test
(FAST) and the Los Angeles Prehospital Stroke Scale(LAPSS). Either can be administered by the ED nurse intriage or by paramedics before reaching the emergency
department. Patient information from these assessment tools
can be re-verified by the ED nurse, physician, or critical carenurse using the more comprehensive National Institutes of
Health Stroke Scale (NIHSS)[13]. The NIHSS provides a
standardized baseline and consistent set of parameters thatcan be repeated throughout the hospital stay. Some stroke
centers order a CT scan based on results of the FAST or
LAPSS and then carry out the NIHSS assessment on thepatient’s return to the ED after imaging is complete.
Many have seen how the neurologic effects of low serum
glucose(dextrose) levels can mimic the symptoms of acutestroke. A finger-stick glucose test should be done early torule out hypoglycemia. In fact, if the glucose level was done
pre-hospital and results were marginal, a repeat finger-stick
test might be in order.
In the acute stroke patient, hyperglycemia is a predictorof poor outcome. Stress of a stroke has been seen to increase
blood sugar even in the nondiabetic. Hyperglycemia isassociated with longer hospital stays(7.2days vs. 6days),increased risk of bleeding into the penumbra, and anincreased risk for death at 30days[14]. The stroke patients
who have their blood sugar tightly controlled early on withhourly blood glucose checks and intravenous insulin, seem tohave less bleeding into the penumbra, and better outcomes.
Conclusions
Public awareness of stroke symptoms as well as rapid andeffective assessment of suspected stroke is critical for
optimum patient outcomes.
Rapid and accurate assessment of patients with suspected
stroke by emergency nursing personnel is essential. The earlystages of patient stabilization and diagnosis are critical tobrain function; thus, it is imperative to assess, monitor, andcorrect the ABCDs during emergency stroke management.
These initial steps are not only crucial for maintaining brain
function, but are invaluable for salvaging penumbral cells.
Moreover, the prompt recognition of stroke will lead toAuthor address

E-Mail: anaba100@yonsei.ac.kr

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DEVELOPMENT of a JAPANESE FUNCTIONAL HEALTH LITERACY TEST
K. Nakagami1), T. Yamauchi1)1) Department of Nursing, School of Health Sciences, Nagoya University, Nagoya, Japan

English speakers. TOFHLA was developed to measure theparticipants’ ability to successfully complete basic numeracy
and reading health literacy skills in 2001. This test includes one
numeracy and two reading passages to assess comprehension oflabeled prescription vials and hospital forms. This has been alsoutilized by only English speakers, because these questions are
based on the American health care system. Thus, it is invalid toappraise the Japanese functional health literacy. Japanese healthknowledge test was developed to estimate health knowledge
among general public, and in identifying and characterizing
Japanese with poor health knowledge, in 2010. This test is only
able to measure knowledge of 15 health related vocabularies forordinary people. In a health care setting, it is required tomeasure patient s’ abilities that focus on not only knowledge but
skills relating primarily to health care settings. Therefore, there
has been no scale or test to measure ability of Japanesefunctional health literacy yet. We will develop and examinefunctional health literacy test for Japanese adults.

Introduction:
The importance of health literacy has been highlighted inrelation to health prevention and the health promotion.
“Health literacy is a topic that has been gaining momentum
over the past few years, in the policy research agendas ofmany countries” [1]. Thus a major goal of the World HealthOraganization, Healthy People 2010, and the Joint
Commission is to improve health communication quality andprovide safe healthcare for patients with low health literacy[2-4].
Nutbeam [5] suggested that functional health literacy was
one of the subordinate concepts of health literacy, in which
there were two other conceptual configurations, interactive
health literacy and critical health literacy. According to
Nutbeam [5], Speros [6] and Mancuso [7], health literacy is
cognitive and social skills, ability of individuals to gain
access to, understand, and use health information that
promote and maintain good health. Thus, functional healthliteracy is that person’s ability to numerate, read, andcomprehend basic medical terms required to function in thehealth care environment. Furthermore, it takes various forms
such as; basic numeracy, reading and comprehension skill
that allow a person to function in the health careenvironment; the ability to apply literacy skills to material
such as prescriptions, appointment cards, medicine
instructions, and directions for self-management of diseases
and conditions; the abilities to understand and act on
information and instructions from professionals, for example
informed consent form or brochures; and patient informationseeking and shared decision-making with healthprofessionals.
In the United States and other developed countries,
evidence shows that patients with inadequate health literacy
have lower adherence to medical instructions [8], lower useof preventive services [9, 10], poor understanding of one’s
medical condition, being into a difficult situation to seek the
medical information by oneself [11], higher hospitalization[11, 12], and increased mortality [13]. In recent studies,
between 40 and 50% of U.S. adults with lack of the reading
and numeracy skills to fully understand the healthinformation are substantial [14]. Kim indicated that 35% of
Korean adults had low functional helath literacy level, below
Korean elementray school level [15]. Tokuda showed thatabout 36% of Japanese people had poor health knowledge[16]. Japanese literacy rates are very high, as most people areable to read easy texts as well as newspaper, but we have tokeep in mind that most Japanese patients can understandwhat medical staff said and showed instruction papers. Now,
there are likely to be certain evidence about the relationshipbetween the inadequate health literacy and health outcomes.
This evidence has been shown by two English healthliteracy tests, such as Rapid Estimate of Adult Literacy in
Medicine (REALM) [17] and The Test of Functional Health
Literacy in Adults (TOFHLA) [18], and one Japanese healthknowledge test, Japanese Health Knowledge Test [16].
REALM, was developed in 1995, and has been used mostfrequently. This test includes only assessing pronounciationof the medical terms correctly. This has been utilized by only

Methods:
Study participants
The data for study will be collected from about three hundred
fifty out patients, whose first language is Japanese, are age 22
years or over, can answer very easy questions such as where
he/she lives at then and what day is then, are not blind and deaf.
Patients younger than 22 years old will be excluded, because
one of the aims of this study includes evaluating the potential
relationship between the functional health literacy and the final
educational attainment. Medical service personnel, such as
physicians, nurses, pharmacists, hospital workers, andcaregivers, will be excluded.
Development of the Japanese Functional Health Literacy Test
(J-FHLT)
This study is designed for a survey to examine the constructvalidity and the item adequacy. First item pool of 72 wasgenerated based on REALM, TOFHLA, J-HKT, and empiricalreferents, such as Japanese medical system, health education or
information materials from physicians or nurses, prescriptions
or materials for medicine, and information documents of X-ray
examination or endoscopic examination.
The first item pool was examined by an advisory panel ofnine nursing students in the first field test, and it was refinedand reduced items to 34 items.
The second item pool consisted of three scales: eightnumeracy items, fifteen reading items, and elevencomprehension items. Content validity for this second item pool
was tested by ten content experts panel, such as two doctors,
two medical researchers, two nurses, two pharmacists, two
educational researchers. These experts were given a rating form
with functional health literacy definition and items. They wererequired to review each item for validity, difficulty, andreadability with a 4-point scale (from 1 = no valid to 4 = very
valid). At the present stage, we calculate the index of content
validity (CVI). CVI is classified according to Lynn’s criteria[19] that are related as over 3 by the experts and the medianover 3.

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Data collection
This study also collects demographic and socioeconomic
data. Demographic data is comprised of age, sex, annual
income, final educational attainment, and occupation.
Furthermore, we measure three questions, translated into
Japanese, from the Health Literacy Screening Questions(HLSQ) [20] and J-HKT for calculating criterion-related
validity. Three questions of the HLSQ, “how often do you
have someone help you read hospital materials?”, “howconfident are you filling out medical forms by yourself?”,and “how often do you have problems learning about your
medical condition because of difficulty understanding written
information?” were each effective 5-point Likert screening
tests for inadequate health literacy in the U.S. patients.
Planning schedule: Fig. 1
Frist of all, we are trying to refine the second item poolbased on CVI and the median.
Second, we will conduct the second field test with about
fifteen out-patients and refining the item pool again.
Third, the second item pool based on the field test will be
generated.
Forth, the second item pool will be tested with about threehundred fifty out-patients as third field test.
Fifth, we will go over factor analysis and calculate internalconsistency reliability (Cronbach’s alpha) and criterionrelated validity (validity coefficient) from third field test data.
We also use the Rasch analysis to evaluate the adequacy of
items. Taking advantage of Rasch analysis, we calculate itemdifficulty, item-fit indices, and person separation reliability inorder to exhibit the degree to which individual items clarify
the unidimensionality of the construct “health literacy.”
Sixth, for the purpose of taking a final check, we willrecalculate internal consistency reliability (Cronbach’s alpha)and criterion-related validity (validity coefficient) by use ofdata from third field test.

Fig. 1 schedule for the study.

References[1] Protheroe J, Wallace SL, Rowlands G, DeVoe JE. Healthliteracy: setting an international collaborative research agenda.
BMC Family Practice. 2009;10(51):1-11.
[2] World Health Organization. Health promotion: report by the
Secretariat. Geneva: World Health Organization; 2000.
[3] U.S. Dept. of Health and Human Services. Healthy people
2010: understanding and improving health. Washington (DC):U.S. Government Printing Office; 2000.
[4] The Joint Commission on the Accreditation of Healthcare
Organizations. [Accessed 21 Sep 2010]. Available at:www.jointcommission.org[5] Nutbeam D. Health Literacy as a public health goal: achallenge
for contemporary
healtheducationandcommunication strategies into the 21st century. Health
Promotion International. 2000;15:259-267.
[6] Speros C. Health literacy: concept analysis. J of Advanced
Nursing. 2005; 50(6): 633-640.
[7] Mancuso JC. Health Literacy: A concept/ dimensional
analysis. J of Nursing and Health Science. 2008;10:248-255.
[8] Gazmararian J, Jacobson KL, Pan Y, Schmotzer
B, Kripalani SA. Effect of a pharmacy-based health literacy
intervention and patient characteristics on medication refill
adherence in an urban health system. Pharmacother. 2010;
44(1):80-7.
[9] Sudore RL, Mehta KM, Simonsick EM, Harris TB,
NewmanAB, Satterfield S, Rosano C, Rooks RN, Rubin SM,
Ayonayon HN, Yaffe K. Limited literacy in older people anddisparities in health and healthcare access, J Am Geriatric Soc
2006;54:770–776.
[10] Baker DW, Gazmararian JA, Williams MV, Scott T, Parker
RM, Green D, Ren J, Peel J. Health literacy and use of
outpatient physician services by Medicare managed care
enrollees, J Gen Intern Med, 2004;19:215–220.
[11] Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone
MP. Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19:1228–1239.
[12] Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin
K, Coates WC, Nurss JR. Inadequate functional health literacy
among patients at two public hospitals, JAMA,
1995;274(21):1677-82.
[13] Baker DW, Wolf MS, Feinglass J. Thompson JA.
Gazmararian JA. Huang J. Health literacy and mortality among
elderlypersons.
ArchivesofInternal
Medicine.
2007;167(14):1503-1509.
[14] Kutner M, Greenbery E, Baer J. National Center for
Education Statistics. Washington (DC): US Dept. of Education.
2005. A first look at the literacy of America’s adults in the 21st
century.
[15] Kim SS, Lee E, The influence of functional literacy onperceived health status in Korean older adults. J Korean Acad
Nurs. 2008;38:195-203.
[16] Tokuda Y, Okubo T, Yanai H, Doba N. Development andvalidation of a 15-item Japanese Health Knowledge Test.
Journal of Epidemiology. 2010;20(4):319-328.
[17] Davis TC, Long SW, Jackson RH, Mayeaux WD. George
RB. Murphy PW. Crouch MA. Rapid estimate of adult literacy
in medicine: A shortened screening instrument. Family
Medicine. 1993;25(6):391-395.
[18] Nurss JR, Parker RM, Baker DW. TOFHLA: Test of
Functional Health Literacy in Adults. Peppercorn Books andPress, Inc. Snow Camp, NC, 2001.
[19] Lynn MR. Determination and quantification of content
validity, Nurs Res, 1986;35:382-385.
[20] Chew D L, Bradley AK, Boyko JE. Brief Questions to
Identify Patients With Inadequate Health Literacy. Family
Medicine. 2004;36(8):588-594.
Author address E-Mail: pellakonk@gmail.com

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Related Factors of Self-Efficacy in Cancer Outpatients Receiving Chemotherapy
in the National University Hospital
A. Hayashi1), S. Ando2)
1) Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Nursing, School of Health Sciences, Nagoya University, Nagoya, Japan

lower among jobless patients and patients having solitary life.
The score of all three subscales was significantly lower among
the patients who do not have hobby, the outpatients receiving
chemotherapy for 1-2 years and the patients whose PS is morethan 1. And the score of ARE and ADE were significantly lower
among the patients with no adviser or difficulty in consulting
doctors or nurses. The score of SCE was significantly lower,
only among the patients with difficulty in consulting nurses.
These findings suggest that nurses take an important role in thesymptom management for the patient. They also suggested that
we must support the outpatients in consideration of theirindividual backgrounds and provide the environment where
outpatients are easy to consult.
Relation between their needs in terms of home care and selfefficacy: The score of all three subscales was significantly lower
among the patients having troubles with adverse effectmanagement. In detail, the score of SCE and ADE weresignificantly lower among the patients who cannot cope withthe aggravation of general condition due to severe symptom andthose who cannot go out alone. And the score of ARE wassignificantly lower among the patients who cannot eat what theywant. And also, the score of all three subscales was significantly
lower among the patients who do not have an adviser and those
who cannot express their feeling well. The score of ADE wassignificantly lower among the patients who feel anxious about arelationship with the doctor. As a result, these findings suggest
the necessity to support the patients having these factors andtheir family in early stage.
Relation between physical symptom and self-efficacy: The
severity of the following physical symptoms significantly
affected the SEAC score: insomnia, inappetence, dyspnea, andfatigue. In detail, the score of ARE was significantly affected byinsomnia and fatigue. The score of SCE was significantly
affected by appetite loss and dyspnea. The score of ADE wassignificantly affected by appetite loss and insomnia. As a result,these findings suggest that the nursing system to improve thesymptom management and self-caring behavior should beestablished.
Relation between QOL/ Psychological distress and selfefficacy: The scores of the distress thermometer weresignificantly affected by ARE and ADE, and the scores of QOL
were also significantly affected by ADE and ARE. In addition, asignificant negative correlation was seen between the distressthermometer and QOL. The nursing care which enhances selfefficacy comprehensively can be the essential for the cancer
outpatients (Figure 1).

Introduction
After the medical fee for outpatient cancer chemotherapy
was accepted in 2002, the place of chemotherapy has beenshifting from hospitalization to outpatient care. Owing to the
outpatient chemotherapy, patients can spend daily life
receiving chemotherapy, and it contributes to improving their
QOL. On the other hand, good self-caring behavior isessential to improve the QOL, and to display good selfcaring behavior, patients need to possess high self-efficacy.
PurposeThis study aimed to identify by a survey questionnaire
the factors related to self-efficacy in cancer outpatients
receiving chemotherapy, and to discuss the appropriate
nursing care for them.
Methods
Subjects: The subjects consisted of 169 cancer
outpatients receiving chemotherapy at the national university
hospital’s chemotherapy center from August to September in2009. The study was approved by the Nagoya University’s
ethical committee and hospital’s ethical committee, andinformed consent was obtained from each patient.
Questionnaire:
The questionnaire covered patient
backgrounds, their needs in terms of home care, a Screening
Questionnaire (physical symptoms, the Severity Distress
Thermometer, overall quality of life) and the Self-Efficacy
Scale for Advanced Cancer (SEAC). SEAC consisted ofthree subscales; Affect Regulation Efficacy (ARE), Symptom
Coping Efficacy (SCE) and ADL Efficacy (ADE).
Data analysis: The relation between self-efficacy andpatient backgrounds and their needs was analyzed using thefollowing statistical analysis: Mann-Whitney’s U test,
Kruskal-Wallis test with Bonferroni correction for multiple
comparisons. And relation between self-efficacy and physicalsymptoms, QOL/ psychological distress was analyzed using
the following statistical analysis: Spearman rank correlation
coefficient, multiple linear regression analysis. PASW
version 17.0 for Windows was applied for data analysis.
Significance was set at P<0.05.
Results and discussion
The average age of the participants was 59.2 years old,and 43.2% of the participants were males, 56.8% werefemales. On Performance Status, PS0 was 34.3%, PS1 was
56.8%. On primary site, 30.2% of participants had breast
cancer, 23.1% had gallbladder or pancreatic cancer, 18.9%
had colorectal cancer.
The relation between patient backgrounds and selfefficacy: The score of SEAC was significantly lower among
patients with the following backgrounds: under 40 years old,jobless, solitary life, PS1 or more, no hobby, no adviser, anddifficulty in consulting doctors or nurses. In detail, the scoreof ARE and SCE were significantly lower among the patients
under 40 years old, and the score of ADE was significantly

Conclusions
We identified the following factors of self-efficacy incancer outpatients receiving chemotherapy: patient backgrounds,
physical symptoms, patient’s needs in terms of home care.
For improving their self-efficacy, it is significant tounderstand patient's background and their needs sufficiently andto support them individually. And we must make an effort toN-6

palliate the following symptoms especially: insomnia, fatigue,
appetite loss, dyspnea.
To generalize these findings, it is necessary to investigate
a longitudinal study in the future.
References[1]Hirai K, Suzuki Y, Tsuneto S, et al. (2002): A structuralmodel of the relationships among self-efficacy,
psychological adjustment, and physical condition in
Japanese advanced cancer patients. Psychooncology,
11(3),221-229.
[2]Morita T, Fujimoto K, Namba M, et al. (2008): Palliative
care needs of cancer outpatients receiving chemotherapy;
An audit of a clinical screening project. Support Care
Cancer,16(1),101-107.
Author address

E-Mail: akiko.H.12@gmail.com

Patient backgrounds• Age• Working status• The number of people living
together• Performance status• The presence of an adviser• Consulting Doctors / Nurses easily• Hobby
Physical symptom• Insomnia• Appetite loss
• Dyspnea• Fatigue

Self Efficacy
for Advanced Cancer
Affect Regulation Efficacy
Symptom Coping Efficacy
ADL Efficacy•••

Patient’s needs in terms of home care

• I want to know about adverse effectmanagement.
• I want to go out alone.
• I want to eat what I want.
• I want an adviser.
• I want to express my feeling well.
• I want to make a better relation withthe doctor.

Figure 1

Related Factors of Self-Efficacy in Cancer Outpatients Receiving Chemotherapy

N-6

Psychologicaldistress reduction,and QOL
improvement