January-February 2018 • Vol. 27No. 138Hillary Jenson, BSN.docx

January-February 2018 • Vol. 27/No. 138
Hillary Jenson, BSN, RN, PCCN, is Registered Nurse,
Providence Portland Medical Center,
Portland, OR; and DNP-FNP student, University of Portland,
Portland, OR.
Sandra Maddux, DNP, APRN, CNS-BC, is Senior Regional
Director, Providence Health and
Services, Oregon Region, Portland, OR.
Mary Waldo, PhD, RN, GCNS-BC, CPHQ, is Regional Director,
Providence Health and
Services, Oregon Region, Portland, OR.
Improving Oral Care in Hospitalized
Non-Ventilated Patients:
Standardizing Products and Protocol
P
atients who develop ventila-
tor-acquired pneumonia have
estimated attributable mor-
tality rates of approximately 10%
(Klompas et al., 2014). To reduce
these rates, healthcare advocacy
groups have endorsed a prevention
bundle that includes routine oral
care (Centers for Medicare &
Medicaid Services, 2017). In a hall-
mark study, DeRiso, Ladowski,
Dillon, Justice, and Peterson (1996)

demonstrated use of the oral anti-
septic chlorhexidine reduced rates
of hospital-acquired pneumonia in
ventilated patients undergoing
coronary artery bypass surgery.
Although routine oral care histori-
cally has been a part of daily patient
care, its significance in preventing
non-ventilator hospital-acquired
pneumonia (NV-HAP) has emerged
as an important preventive meas-
ure. Maeda and Akagi (2014) linked
poor oral health with an increased
risk for infection and thus NV-HAP.
Research also has demonstrated
that without regular oral hygiene,
bacteria remain in the oral cavity
and become more pathogenic over
time (Ikeda et al., 2014). Despite
these risks, research suggests imple-
mentation of regular, high-quality
oral care by nursing staff often is
neglected due to barriers in practice
(Letsos, Ryall-Henke, Beal, &
Tomaszewski, 2013). These barriers
include limited time, resource con-
straints, challenging patient behav-
iors, and staff knowledge gaps
regarding appropriate frequency in
oral care.
Although every patient benefits
from routine oral care, some groups
are at higher risk of developing NV-
HAP. These include recently extu-

bated persons, postoperative pa -
tients, and patients managed on
progressive care units (Scheel,
Pisegna, McNally, Noordzij, &
Langmore, 2016); and patients
strictly receiving nothing by mouth
or with dysphagia (Maeda & Akagi,
2014). These patients, who are seen
commonly in the medical-surgical
setting, require heightened aware-
ness and sensitivity to their oral
care needs.
NV-HAP develops when patients
micro-aspirate oropharyngeal path -
ogens into the lungs (Di Pasquale,
Aliberti, Mantero, Bainchini, &
Blasi, 2016). Organ isms responsible
for the development of NV-HAP
include Staphy lococcus aureus and
gram-negative bacteria, which are
increasingly antibiotic resistant
(Weiner et al., 2016). This knowl-
edge of escalating antibiotic resist-
ance in conjunction with previous-
ly discussed studies demonstrating
the relationship between oral care
and reduction of NV-HAP high-
lights the urgency for nurses to take
action (Kaneoka et al., 2015; Maeda
& Akagi, 2014). Medical-surgical
nurses are in a position to influence
outcomes related to oral care. This
fundamental nursing intervention
warrants further investigation to

ensure these actions become an
essential part of daily patient care.
Purpose
The purpose of this study was to
determine if staff education, imple-
mentation of an oral care protocol,
and alterations to bedside oral care
tools improved the frequency of
oral care in patients who were non-
ventilated and did not have a tra-
cheostomy. A secondary purpose
was to determine if a difference
existed in the frequency of oral care
provided to high-risk populations,
defined as those who had orders to
take nothing by mouth, were tube-
Research for PracticeResearch for Practice
Hillary Jenson
Sandra Maddux
Mary Waldo
Medical-surgical nurses are in a position to influence outcomes
related to oral care. In this study, educating nurses on the
impor-
tance of routine oral care and moving tools to the bedside
improved
the frequency of oral care.
January-February 2018 • Vol. 27/No. 1 39

fed or diagnosed with dysphagia, or
had been extubated recently.
Review of the Literature
A review of the literature from
2013-2017 was conducted in MED-
LINE using search terms oral care in
acute care and oral care in long-term
care.
To determine the effect of oral
care on incidence of pneumonia or
related mortality in adult patients
in hospitals or long-term care facili-
ties, Kaneoka and co-authors (2015)
conducted a comprehensive litera-
ture review and meta-analysis of
primary, randomized controlled tri-
als. Five studies met defined inclu-
sion criteria; one of them had no
reported pneumonia during the
data collection period and was not
included in the meta-analysis.
Authors concluded the pooled
effect of oral care with topical
chlorhexidine or mechanical oral
care contributed to significantly
reduced risk for developing pneu-
monia compared to control
(p=0.02). Additionally, the effect of
oral care on reducing fatal pneumo-
nia was significant (p=0.02). This
meta-analysis dem onstrated routine

oral care positively correlates to
improved outcomes among non-
ventilated patients.
To reduce complications second-
ary to pneumonia, Maeda and Akagi
(2014) evaluated the effect of regular
oral care among 63 immobile older
adult patients (mean age=81.7, + 2.5
years) who received nutrition solely
via tube feedings and nothing by
mouth. Authors noted lack of oral
intake can alter the pathogenicity of
the oral cavity and, combined with
higher rates of aspiration in elders,
lead to increased risk of NV-HAP. A
year-long intervention study includ-
ed control and oral care interven-
tion groups; the intervention group
received mechanical oral care using
chlorhexidine, a mouth moisturizer
with glyceryl gel, and salivary gland
massage. The intervention group
had significant reduction in the
incidence of pneumonia, number of
febrile days, number of days with
antibiotics, and rate of blood and
radiological tests (p<0.05). This
study underscores the importance of
regular oral care on health to
improve outcomes in high-risk per-
sons.
Despite evidence of a correlation
between oral care and improved

outcomes, Pettit, McCann, Schneid -
erman, Farren, and Campbell
(2012) identified a knowledge gap
when surveying a random sample
of 98 registered nurses. The mailed
50-question survey assessed oral
care knowledge, practices and per-
ceptions of importance, and barriers
to providing oral care. Results indi-
cated 95% of respondents (n=93)
believed oral care was important
and 79% (n=77) felt responsible for
providing oral care; however, 52%
(n=51) indicated oral care was
addressed minimally in their nurs-
ing education. Although the per-
ceived lack of education, 67%
(n=66) reported being knowledgeable
or very knowledgeable about oral
care. Participant scores on survey
questions related to oral care knowl-
edge did not correspond to the per-
ceived knowledge reported (mean
test score 50.5%, SD=0.132). Per -
ceived barriers to performing oral
care included low priority, lack of
time, lack of resources, and no
employer mandate for its provision.
These responses reflected a knowl-
edge gap regarding oral care and
identified potential barriers to rou-
tine, nurse-driven oral care. Creat -
ing an intervention that educates to
deficits in nursing knowledge and
Background

Daily oral care is known to reduce microorganisms in the oral
cavity and
may reduce the risk of infection caused by aspiration (Kaneoka
et al.,
2015). This practice may be overlooked among non-ventilated
patients.
Purpose
To determine if staff education, a standardized protocol, and
bedside
tools improved frequency of oral care.
Method
A pre-post design was used in a study of patients who were non-
ventilat-
ed and without tracheostomies. Chart reviews determined the
frequency
of oral care pre-intervention compared to weeks 5, 7, and 9
following
intervention. Oral care knowledge and perceived barriers to oral
care were
assessed and analyzed.
Findings
Oral care documentation improved from pre-intervention rates
com-
pared to weeks 5 and 9 (p<0.01); from weeks 5 to 7 (p=0.00);
and main-
tained through week 9 (p=0.00). Nurses demonstrated increased
aware-
ness after intervention for oral care need (p=0.005), high-risk
populations

(p=0.001), benefits to patient’s self-esteem (p=0.026), and
opportunity to
assess oral health (p=0.006).
Limitations and Implications
An inability to generalize findings to other populations due to
inaccessi-
ble demographics on patients was a limitation of the study.
Results imply
an existing knowledge gap among nurses regarding need for oral
care in
high-risk patients.
Conclusion
Educating nurses on the importance of routine oral care and
moving tools
to the bedside improved the frequency of oral care.
Longitudinal studies
are needed to determine if oral care prevents aspiration
pneumonia.
Improving Oral Care in Hospitalized Non-Ventilated Patients:
Standardizing Products and Protocols
reduces barriers in delivering oral
care may result in more effective
adoption of the practice.
Quinn and Baker (2015) also
conducted a gap analysis on nurs-

ing oral care practice in the inpa-
tient setting. While results of the
gap analysis were not reported,
authors created an evidence-based,
multi-pronged intervention to
determine the effect of quality, rou-
tine oral care on patient outcomes.
The first aspect of the intervention
addressed inadequate and inappro-
priate supplies within the system,
including toothbrushes that did not
comply with American Dental
Association guidelines and lack of
availability of suction toothbrushes.
The second component of the inter-
vention involved updating the sys-
tem’s oral care protocol to include
patients of all acuities, from those
independent in oral care to those
with complete dependency. The
third prong of the intervention
incorporated modification of exist-
ing documentation to enable prop-
er charting of oral care perform-
ance. Finally, nursing staff knowl-
edge was surveyed before and after
the intervention. Information from
the baseline survey was used to
develop an educational program for
nursing staff. In the following year,
hospitalized patients were less likely
to acquire NV-HAP (49% decline,
p<0.001). In addition, an estimated
$2.4 million were saved secondary
to reduced hospital stays; return on
investment was an estimated $2.28

million. This study demonstrated
education plus easy-to-use and
ready-to-go equipment are effective
in reducing healthcare costs,
improving patient outcomes, and
effecting change among clinical
providers in an inpatient setting.
This review of the literature sup-
ports the need for providing oral
care to non-ventilated, hospitalized
patients. A need exists for a low-
cost, highly effective means of
enhancing medical-surgical nurses’
delivery of regular oral care.
Ethics
This study received approval
from the Institutional Review Board
at Providence Health and Services
(Portland, OR). A conflict of interest
agreement was established with the
manufacturer of the oral care kits
prior to implementation of the
study. The staff received an invita-
tion to participate in completion of
the survey, which indicated their
willingness to participate in the
study. Because patient data were
extracted from existing medical
records, consent was not required.
Sample Selection

Patient Sample
Through a retrospective chart
review, baseline oral care data were
gathered from a convenience sam-
ple of 50 patients admitted in June
2015. Patients were included if they
did not have a ventilator or a tra-
cheostomy. Post-intervention data
were collected using the same exclu-
sion criteria for patients admitted
August-Septem ber 2015.
Staff Sample
All regularly scheduled staff on
the medical-surgical progressive
care unit (PCU) were invited via
email to participate in the online
pre-intervention survey during June
2015. A reminder email was sent 1
week after the initial invitation.
Consent was implied through sur-
vey completion, and all responses
were anonymous. After the inter-
vention was implemented, regular-
ly scheduled staff again were invit-
ed to participate in a post-interven-
tion survey.
Design and Method
This pre- and post-interventional
study was conducted at a metropol-
itan, not-for-profit, Magnet®-desig-
nated facility in the northwestern

United States. Registered nurses
(RNs) and certified nurse assistants
(CNAs) from a medical-surgical
PCU were invited to participate.
The intervention included an edu-
cational in-service for nursing staff,
implementation of an oral care pro-
tocol, and adoption of a daily oral
hygiene kit located at the bedside.
Data were collected via retrospec-
tive chart audit for patients who
met inclusion criteria. Staff knowl-
edge was assessed using an online
questionnaire developed by the
investigators.
The seven-item multiple-choice
questionnaire was used to deter-
mine staff knowledge regarding the
importance of oral care practices on
the unit and barriers encountered
in providing regular oral care. The
questionnaire was developed after
team members conducted an exten-
sive literature review. A master’s-
prepared nurse manager with ex -
pertise in the care of high-acuity
patients with respiratory disorders
determined face validity of the staff
survey. In addition, the survey was
evaluated for readability and clarity
by content experts from among
clinical staff not participating in the
study as well as staff from the
Speech Pathology Department. It

was determined to be appropriate
for administration to nursing staff.
An external clinical nurse special-
ist (CNS) with national recognition
in acute and critical care was invited
to provide the intervention educa-
tion. After the literature re view, the
research team suggested content
and collaborated with the CNS in
development of the education inter-
vention. This CNS conducted an
original 1-hour presentation on the
impact of oral hygiene practices in
eliminating NV-HAP in the acute
care setting. Included were methods
to ease adoption of practice im -
provements. The session was record-
ed and a digital video disc copy
made available to staff members
who were unable to attend. The
CNS also provided personalized edu-
cation to staff members who were
involved in direct patient care at the
time of the presentation.
A convenience sample of pat -
ients was selected from the daily
census before the intervention and
at 5, 7, and 9 weeks after interven-
tion. An electronic health record
data collection tool was developed
to assess the frequency of patient
refusal and completion of oral care
documentation by nursing staff.
Inter-rater reliability for chart audits

was established after researchers
independently reviewed charts and
Research for Practice
achieved 100% agreement. Addit -
ionally, the data collection tool was
used to identify the frequency of
factors that place patients at higher
risk for aspiration pneumonia:
being unable to take anything by
mouth, having a modified diet tex-
ture or liquid consistency, and/or
using a tube feeding (Maeda &
Akagi, 2014).
To enhance the ability of staff
members to deliver oral hygiene,
the study site trialed a pre-packed
kit (Q•Care®; Sage Products LLC)
consisting of four tear-off oral
hygiene kits to be used throughout
a 24-hour period. All four sections
contained a combination antiseptic
cleanser and mouth moisturizer.
Two of the kits contained a suction
toothbrush and the other two kits
contained a suction swab. The
product was placed at the head of
the patient’s bed each morning by
night staff to provide a visual cue
for oncoming staff to perform oral

hygiene. A representative from the
manufacturer was trained on the
study protocol and provided just-
in-time training over 1 week for day
and night shift staff before imple-
mentation of the intervention.
An oral hygiene guideline
(adapted with permission from
Quinn & Baker, 2015) was imple-
mented for patients without a tra-
cheostomy or who were not ventila-
tor-dependent. This protocol speci-
fied patients were to receive oral
hygiene using the oral care kits four
times a day. Patients who were
capable of self-administering hy -
giene were encouraged to use the
product with supervision. Staff were
trained to document completion of
oral hygiene or patient refusal. The
protocol was posted strategically
around the unit, emailed to staff,
and kept at the charge nurse station
for easy access and reference. See
Table 1 for the protocol.
Findings
Data were entered into Statistical
Package for Social Sciences (SPSS),
version 22. Chi-square was used to
compare perceived frequency, barri-
ers and benefits of performing oral
care, and populations at risk for de -

veloping NV-HAP. One-way ANOVA
was performed to determine the dif-
ferences in documentation of oral
care between the baseline and 5, 7,
and 9 weeks after education. A priori
significance was determined to be
p<0.05. A power analysis deter-
mined the appropriate sample size
to detect significance to be at least
40 patients per collection period.
Analysis on role differences was not
conducted as no CNAs completed
the post-intervention survey.
Survey results found no statisti-
cally significant difference after
intervention in staff perception of
the importance of ensuring regular
oral care (chi-square p=0.22). Using
Pearson’s chi-square, researchers
analyzed barriers to performing oral
care, and staff understanding of
benefits and patients at risk to
determine differences in responses
in before- (n=23) and after-educa-
tion surveys (n=16) (see Table 2).
Significant differences were found
in the following areas: awareness of
an oral care protocol for patients
without a tracheostomy and not
ventilated, and increased risk of
TABLE 1.
Oral Care Protocol

Dental Condition Supplies Procedure Frequency
No dentures Oral Care Kit
• Use brush
attachment before
breakfast and dinner.
• Use swab
attachment before
lunch and at bedtime.
Moisten suction toothbrush in antiseptic oral rinse.
Connect suction toothbrush to continuous suction.
Brush teeth for 1-2 minutes.
Suction debris from mouth.
Discard disposable equipment in appropriate
receptacle.
Before each meal
and at bedtime
Dentures Labeled denture cup
Soft toothbrush
Denture cleaner for
soaking only
Two swabs
Alcohol-free antiseptic
rinse
Denture adhesive
(optional)
Remove dentures and place in labeled denture cup.
Brush palate, buccal surfaces, gums, and tongue
with swab.
Have patient swish and spit antiseptic rinse or use
swab to apply rinse.

Carefully brush dentures with warm water. Do not
use toothpaste, which may scratch dentures.
Help patient insert dentures in mouth.
After bedtime mouth care, soak dentures in
commercial cleanser in denture cup.
If patient needs adhesive to hold dentures firmly in
place, follow manufacturer directions.
Before each meal
and at bedtime
Source: Adapted from Quinn & Baker, 2015
TABLE 2.
Chi-Square
Question df
Pre-Intervention
Replied “No”
Post-Intervention
Replied “No”
Chi-Square
Result
Exact
Significance
(two-sided)

On a typical day, which of the following are
barriers to performing regular oral care with
your patients (No/Yes):
• Lack of time
• Lack of supplies
• Other tasks take priority
• Lack of support staff
• Patient refusal
• Not something I give much thought to
1
1
1
1
1
1
n = 6
n = 22
n = 5
n = 11
n = 16
n = 18
n = 6
n = 15
n = 4
n = 10
n = 8
n = 15
0.58
0.07
0.06
0.82

1.53
1.74
p = 0.50
p = 1.0
p = 1.0
p = 0.52
p = 0.32
p = 0.37
Are you aware of a protocol in place for oral
care among non-trached, non-ventilated
patients? (Not aware/Aware)
1 n = 8 n = 6 6.24 p = 0.018*
What benefits do you see to performing regular
oral care with non-trached, non-ventilated
patients (Yes/No)
• Improved self-esteem
• Increased oral intake
• Reduced chance for infection
• Opportunity to assess patient’s oral health
1
1
1
1
n = 8
n = 10
n = 2
n = 9
n = 3
n = 8

n = 3
n = 3
1.20
0.16
0.85
1.84
p = 0.47
p = 0.75
p = 0.63
p = 0.29
Which of the following patients are most at risk
for developing non-ventilator hospital-acquired
pneumonia? (Yes/No)
• NPO patients
• Post-surgical patients
• Dysphagia patients
• Tube feeding patients
• Critically ill patients
1
1
1
1
1
n = 8
n = 3
n = 1
n = 3
n = 0
n = 0
n = 0

n = 0
n = 2
n = 0
7.00
2.26
0.71
0.002
NA
p = 0.01**
p = 0.26
p = 1.0
p = 1.0
NA
NPO = nothing by mouth
*p ≤ 0.05, **=0.00
Variable Sum Squares df Mean Square F Significance
Patient age B = 1173.3
W = 27538.1
3
156
391.11
176.5
2.216 0.088
Documentation: Number of times oral care refused B = 11.42
W = 108.8

3
156
3.8
0.70
5.459 0.001*
Documentation: Number of times oral care charted B = 69.2
W = 159.0
3
156
23.1
1.0
22.634 0.000*
NPO B = 0.17
W = 8.3
3
156
0.06
0.05
1.054 0.0370
Diet texture B = 22.8
W = 713.4
3
156

7.6
4.6
1.663 0.177
Liquid consistency B = 18.6
W = 693.1
3
156
6.2
4.4
1.393 0.247
Presence of tube feeding B = 0.6
W = 7.0
3
156
0.2
0.05
4.457 0.005*
TABLE 3.
Differences in Means Among the Four Data Collection Periods,
ANOVA
B = between, NPO = nothing by mouth, W = within
*p ≤ 0.05
Research for Practice

patients allowed nothing by mouth
(NPO) of developing NV-HAP.
Analysis of variance (ANOVA)
was used to compare changes in
patients’ documented oral care over
time. No significant differences
were found in patient age, orders
for nothing by mouth, diet texture,
and liquid consistency (see Table 3).
Statistically significant findings in
number of times oral care was
refused (p=0.001) or charted
(p=0.000), and the presence of tube
feedings (p=0.005) were analyzed
further using the Scheffe test (see
Table 4). This test identified a signif-
icant increase in number of times
oral care was refused from baseline
compared to weeks 7 (p=0.018) and
9 (p=0.006). Further analysis deter-
mined the number of charted oral
care occurrences improved signifi-
cantly from baseline to weeks 5
(p=0.000) and 9 (p=0.007). Signif -
icant improvement in documenta-
tion occurred be tween weeks 5 and
7 (p=0.000), and between weeks 5
(p=0.000) and 9 (p=0.000), but not
between weeks 7 and 9. Six patients

had tube feedings at week 5; this
was a significant change from base-
line (p=0.021) and from week 9
(p=0.021). At baseline and week 9,
no patients had tube feedings.
TABLE 4.
Post Hoc Analysis: Difference in Means Among Four Data
Collection Periods (Scheffe Test)
Dependent Variable
Data Collection
Period
Data
Collection
Period
Mean
Difference Std Error Sig.
95% Confidence Interval
Lower
Bound
Upper
Bound
Documentation:
Number of times oral
care refused
Pre-intervention 5 weeks
7 weeks
9 weeks

-0.3000
-0.6000
-0.6750
0.187
0.187
0.187
0.463
0.018*
0.006*
-0.83
-1.13
-1.2
0.228
-0.07
-0.15
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
0.3000
-0.3000
-0.3750
0.187
0.187
0.187

0.463
0.463
0.262
-0.23
-0.83
-0.90
0.83
0.23
0.15
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.6000
0.3000
-0.075
0.187
0.187
0.187
0.018*
0.463
0.984
0.07
-0.23
-0.60
1.13

0.83
0.45
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.6750
0.3750
0.0750
0.187
0.187
0.187
0.006*
0.262
0.984
0.15
-0.15
-0.45
1.20
0.90
0.60
Documentation:
Number of times oral
care charted
7 weeks

9 weeks
-1.8250
-0.6000
-0.8000
0.226
0.226
0.226
0.000**
0.074
0.007*
-2.47
-1.24
-1.44
-1.19
0.04
-0.16
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
1.825
1.225
1.025
0.226
0.226
0.226

0.000**
0.000**
0.000**
1.19
0.59
0.39
2.46
1.86
1.66
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.6000
-1.225
-0.2000
0.226
0.226
0.226
0.074
0.000**
0.853
-0.04
-1.86
-0.84

1.24
-0.59
0.44
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.8000
-1.025
0.2000
0.226
0.226
0.226
0.007*
0.000*
0.853
0.16
-1.66
-0.44
1.44
-0.39
0.84
Presence of tube
feeding
7 weeks

9 weeks
-0.1500
-0.0500
0.0000
0.047
0.047
0.047
0.021*
0.774
1.000
-0.28
-0.18
-0.13
-0.02
0.08
0.13
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
-0.1500
0.1000
0.1500
0.047
0.047
0.047

0.021*
0.221
0.021*
0.02
-0.03
0.02
0.28
0.23
0.28
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.0500
-0.1000
0.0500
0.047
0.047
0.047
0.774
0.221
0.774
-0.08
-0.23
-0.08

0.18
0.03
0.18
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.0000
-0.1500
-0.0500
0.047
0.047
0.047
1.000
0.021*
0.774
-0.13
-0.28
-0.18
0.13
-0.2
0.08
*p ≤ 0.05; **=0.00

Discussion
Tada and Miura (2012) noted reg-
ular oral care improves a patient’s
ability to eat, drink, and swallow.
However, the current survey found
staff understanding of this relation-
ship did not increase after educa-
tion. In retrospect, the educational
sessions did not emphasize the rela-
tionship between oral care and the
mechanics of swallowing. Prior to
education, staff already demonstrat-
ed insight to the relationship
between oral care and infection.
This remained high after the educa-
tional intervention. Staff perception
improved regarding the impact of
oral care on self-esteem and the
opportunity to assess a patient’s oral
health, but results were not signifi-
cant. The lack of significance is like-
ly due to a smaller sample on the
follow-up survey. Education ap -
peared effective in improving the
ability of staff to identify patients
who were NPO as at higher risk for
developing NV-HAP. Staff demon-
strated increased awareness be -
tween pre- and post-surveys of the
risk of patients developing NV-HAP
if they have dysphagia, or are tube-

fed or critically ill.
The interventions used in this
study did not reduce or remove
known barriers to providing oral
care identified by Letsos and col-
leagues (2013). In the current study,
survey results did not identify
access to supplies and patient coop-
eration as barriers. The greatest bar-
riers to performing oral care for staff
were time availability and task pri-
oritization. The ability to manage
time associated with oral care and
prioritize it among other nursing
demands remained problematic
before and after the intervention.
Interestingly, perception of ade-
quate staffing as a barrier to oral
care did not change; it also was not
perceived to be a strong barrier.
After the intervention, a statisti-
cally significant finding was staff
improvement of their documenta-
tion of oral care performance as
well as patient refusal of oral care.
Baseline data demonstrated limited
documentation in these areas. Staff
education included standardized
documentation requirements for
oral care. The improvement after
intervention may be related to the
increased value placed on oral care
documentation during this study,

or it may indicate practice changed
because of this intervention.
Limitations
The lack of demographic data
collected on the nursing staff and
the patient sample hindered gener-
alizability to other staff and patient
groups. In addition, the lack of CNA
participation in the post-study sur-
vey affected the interpretation of
results. The staff survey was devel-
oped expressly for this study and
therefore does not have demonstrat-
ed reliability or validity. Another
limitation was the un known rate of
education completion by nursing
staff. This study also did not deter-
mine which intervention was most
effective in improving oral care
practices. Finally, patient acuity may
have increased in the post-interven-
tion phase, as demonstrated by the
increased number of patients with
tube feedings. This may have influ-
enced the ability of staff to perform
oral care or their failure to docu-
ment its occurrence over time.
Recommendations …
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First peoples: Study finds two ancient ancestries
'reconverged' with settling of South America
Date: June 17, 2018
From: NewsRx Health
Publisher: NewsRX LLC
Document Type: Article
Length: 966 words
Full Text:
2018 JUN 17 (VerticalNews) -- By a News Reporter-Staff News

Editor at VerticalNews Health -- Recent research has suggested
that
the first people to enter the Americas split into two ancestral
branches, the northern and southern, and that the "southern
branch"
gave rise to all populations in Central and South America.
Now, a study shows for the first time that, deep in their genetic
history, the majority - if not all - of the Indigenous peoples of
the
southern continent retain at least some DNA from the "northern
branch": the direct ancestors of many Native communities living
today
in the Canadian east.
The latest findings, published in the journal Science, reveal
that, while these two populations may have remained separate
for
millennia - long enough for distinct genetic ancestries to emerge
- they came back together before or during the expansion of
people
into South America.
The new analyses of 91 ancient genomes from sites in
California and Canada also provide further evidence that the
first peoples
separated into two populations between 18,000 and 15,000 years
ago. This would have been during or after migrating across the
now-submerged land bridge from Siberia along the coast.
Ancient genomes from sites in Southwest Ontario show that,
after the split, Indigenous ancestors representing the northern
branch
migrated eastwards to the great lakes region. This population
may have followed the retreating glacial edges as the Ice Age
began to

thaw, say researchers.
The study also adds to evidence that the prehistoric people
associated with Clovis culture - named for 13,000-year-old
stone tools
found near Clovis, New Mexico, and once believed to be
ancestral to all Native Americans - originated from ancient
peoples
representing the southern branch.
This southern population likely continued down the Pacific
coast, inhabiting islands along the way. Ancient DNA from the
Californian
Channel Islands shows that initial populations were closely
related to the Clovis people.
Yet contemporary Central and South American genomes reveal
a "reconvergence" of these two branches deep in time. The
scientific
team, led by the universities of Cambridge, UK, and Illinois
Urbana-Champaign, US, say there must have been one or a
number of
"admixture" events between the two populations around 13,000
years ago.
They say that the blending of lineages occurred either in North
America - prior to expansion south - or as people migrated ever
deeper into the southern continent, most likely following the
western coast down.
"It was previously thought that South Americans, and indeed
most Native Americans, derived from one ancestry related to the
Clovis
people," said Dr Toomas Kivisild, co-senior author of the study
from Cambridge's Department of Archaeology.

"We now find that all native populations in North, Central and
South America also draw genetic ancestry from a northern
branch most
closely related to Indigenous peoples of eastern Canada. This
cannot be explained by activity in the last few thousand years.
It is
something altogether more ancient," he said.
Dr Ripan S. Malhi, co-senior author from Illinois Urbana-
Champaign, said: "Working in partnership with Indigenous
communities, we
can now learn more about the intricacies of ancestral histories
in the Americas through advances in paleogenomic
technologies. We
are starting to see that previous models of ancient populations
were unrealistically simple."
Present day Central and South American populations analysed
in the study were found to have a genetic contribution from the
northern branch ranging between 42% to as high as 71% of the
genome.
Surprisingly, the highest proportion of northern branch genetics
in South America was found way down in southern Chile, in the
same
area as the Monte Verde archeological site - one of the oldest
known human settlements in the Americas (over 14,500 years
old).
"It's certainly an intriguing finding, although currently
circumstantial - we don't have ancient DNA to corroborate how
early this
northern ancestral branch arrived," said Dr Christiana Scheib,
first author of the study, who conducted the work while at the

University
of Cambridge.
"It could be evidence for a vanguard population from the
northern branch deep in the southern continent that became
isolated for a
long time - preserving a genetic continuity.
"Prior to 13,000 years ago, expansion into the tip of South
America would have been difficult due to massive ice sheets
blocking the
way. However, the area in Chile where the Monte Verde site is
located was not covered in ice at this time," she said.
"In populations living today across both continents we see much
higher genetic proportions of the southern, Clovis-related
branch.
Perhaps they had some technology or cultural practice that
allowed for faster expansion. This may have pushed the
northern branch
to the edges of the landmass, as well as leading to admixture
encounters."
While consultation efforts varied in this study from community-
based partnerships to more limited engagement, the researchers
argue
that more must be done to include Indigenous communities in
ancient DNA studies in the Americas.
The researchers say that genomic analysis of ancient people can
have adverse consequences for linked Indigenous communities.
Engagement work can help avoid unintended harm to the
community and ensure that Indigenous peoples have a voice in
research.
"The lab-based science should only be a part of the research.

We need to work with Indigenous communities in a more
holistic way,"
added Schieb, who has recently joined the University of Tartu's
Institute of Genomics, where Kivisild also holds an affiliation.
"From the analysis of a single tooth, paleogenomics research
can now offer information on ancient diet and disease as well as
migration. By developing partnerships that incorporate ideas
from Native communities, we can potentially generate results
that are of
direct interest and use to the Indigenous peoples involved," she
said.
Keywords for this news article include: University of
Cambridge.
Our reports deliver fact-based news of research and discoveries
from around the world. Copyright 2018, NewsRx LLC
Copyright: COPYRIGHT 2018 NewsRX LLC
http://www.Newsrx.com
Source Citation (APA 6th Edition)
First peoples: Study finds two ancient ancestries 'reconverged'
with settling of South America. (2018, June 17). NewsRx
Health, 35.
Retrieved from https://link-gale-
com.nuls.idm.oclc.org/apps/doc/A542026579/HWRC?u=nu_mai
n&sid=HWRC&xid=a91ccf39
Gale Document Number: GALE|A542026579
http://www.Newsrx.com
See attached the article
Read the article and write a complete, one-page summary of the
article, making sure to identify the specific argument the author

is making. Include the complete citation at the top of your
summary.
First peoples: Study finds two ancient ancestries “reconverged”
with settling of South America (p. 35–). (2018). NewsRX LLC.
When you finish writing your summary please answer the
following three questions, and write a one paragraph answer to
each question.
1-When you look at a website on the internet, what steps do you
go through to determine what the primary purpose of the site is?
What do you look for? How can you tell if a website is a
reliable source on that topic?
2-If you were going to begin a database search on the topic of
the relationship between individualism and the portrait genre,
what search terms would you use? What are the most significant
terms here—the ones you could NOT leave out? If you searched
“individualism” would this be sufficient?
3-When you are using a source, do you need to cite the source if
you put the information into your own words? Define and
explain plagiarism, and discuss the correct way to use
information from a secondary source.
How to Write a Summary of a Scholarly Article
The goal is to write a short summary of an academic article, to
identify the scholar’s argument, to figure out the main point, to
give your reader (and yourself, later on) a sense of the steps of
the argument, to paraphrase the argument in your own words,
and to produce something that represents the article you just
read.
Why write a summary?
A summary is important so you can go back later (in a few
weeks or so when you actually have to write the final paper)
and read short one-page summaries of the articles instead of
reading the entire, long article again.
A summary requires you to distance yourself from the author of
the work you are reading. You say “the author argues” this or
that, rather than “Women in the French Revolution were” this or

that. This move is essential in academic writing. More on that
later.
Writing a summary enables you to remember the main point that
the author is making in the article. It forces you to find it. The
first time you do one of these is the most difficult, but it's worth
it academically. You are learning a new and valuable skill that
should grow with every class you take.
How to proceed
Choose a peer-reviewed scholarly article. Do NOT use a book
for this assignment. Work with the librarians who will help you
find good databases and help you develop good search terms.
It is a good idea to make a Xerox copy of it or print it out. This
is your copy to mark up, underline, highlight, tear to pieces, all
the things you should do when you read an article.
Underline topic sentences, go back and forth from section to
section, and read the introduction and conclusion as you work
through this article. If you read it once, that is just beginning. If
you read it twice, you MAY begin to get a handle on it. If you
read it more than twice, at least parts of it, you will have an
easier time with this.
Write down what you think the purpose, the audience, the
language, the presentation, and the evidence is for the
argument. What kind of discipline is the author working in?
What are the examples that she/he uses to make her/his points?
Is there any specialized jargon? This is for you, don’t hand this
in. This is pre-writing.
Identify the sentence where the author states the main claim of
the argument.
Make a list of the examples, data, or forms of support that the
writer uses to back up the claim.
Describe the structure of the article—how many sections are
there? How is it laid out? What is the main focus and purpose of
each section of the argument? How does the writer advance the
argument in a logical sequence?
Develop these notes into one-page summary of the argument.

This is what you will submit for the Week One assignment.
Quotes: You may quote phrases of no more than one sentence at
a time. Do not use long quotations in summaries. Write in your
own words.
Representation: Your summary should accurately represent the
article. This is not the place to express your opinion, your
evaluation, your interpretation of the material into this. Save
that for later.
Present tense: Use present tense. “The author says” or
“Campbell uses these examples” are two good ways to start
sentences in a summary.
Be sure to use either MLA or APA style.
CLINICAL SCHOLARSHIP
Using Photovoice to Explore Nigerian Immigrants’ Eating and
Physical Activity in the United States
Melanie T. Turk, PhD, MSN, RN1, Abimbola Fapohunda, DrPH,
MPH, MS2, & Rick Zoucha, PhD, APRN-BC,
CTN-A3
1 Epsilon Phi, Assistant Professor, Duquesne University School
of Nursing, Pittsburgh, PA, USA
2Consultant, FOB Group, LLC, Monroeville, PA, USA
3 Professor of Nursing, Duquesne University School of Nursing,
Pittsburgh, PA, USA
Key words
Immigrants, nutrition, physical activity,
Photovoice

Correspondence
Dr. Melanie T. Turk, Duquesne University School
of Nursing, 518 Fisher Hall, 600 Forbes Avenue,
Pittsburgh, PA 15282. E-mail: [email protected]
Accepted: July 19, 2014
doi: 10.1111/jnu.12105
Abstract
Purpose: African immigrants are one of the fastest growing
immigrant groups
to the United States; there is a crucial need to learn about
African immigrants’
beliefs and lifestyle behaviors that may impact health. The
purposes of this
study were to (a) explore the perceptions and practices of
Nigerian immigrants
regarding healthy eating and physical activity in the United
States; (b) assess
the influence of cultural beliefs of Nigerian immigrants on
eating and physical
activity; (c) describe the role that healthcare providers can play
in helping to
promote healthy eating and physical activity; and (d) evaluate
the feasibility
and efficacy of using Photovoice to collect data on the
perceptions and practices
of Nigerian immigrants regarding healthy eating and physical
activity.
Design: Qualitative visual ethnography using Photovoice.
Methods: Thirteen Nigerian immigrants were recruited. Data
were col-

lected using photography and focus group discussions at a
church. Photovoice
methodology and Leininger’s four phases of qualitative analysis
were used to
analyze photographs, field notes, and focus group transcripts.
Findings: Four overarching themes emerged from the data:
moderation is
healthy, Nigerian ways of living are healthy, acquiring
American ways is un-
healthy, and cultural context is important to promote healthy
behaviors.
Conclusions: Photovoice was a feasible, effective methodology
for collecting
data on the perceptions and practices of Nigerian immigrants.
Nigerian partic-
ipants believed that adherence to traditional dietary and activity
practices are
healthy. Nurses and other healthcare providers must make
concerted efforts
to communicate with and educate Nigerian immigrants about
healthful eating
and activity behaviors within their cultural context.
Clinical Relevance: The number of African immigrants to the
United States
has increased dramatically. Photovoice is a creative method to
learn about the
health beliefs and behaviors of the Nigerian immigrant
population.
Immigration plays a major role in the growth of the
population of the United States, and it is estimated that
82% of the population increase between 2005 and 2050
will be attributable to immigrants and their offspring
(Passel & Cohn, 2008). The African-born population in
the United States doubled in size from 881,300 in 2000
to 1.6 million in 2010, and one of the most common

countries of origin for African immigrants is Nigeria
(U.S. Census Bureau, 2010). Yet, to a large extent, the
health and wellness of the African immigrant population
remain unexplored (Venters & Gany, 2011). These de-
mographic trends indicate a crucial need to learn about
African immigrants’ beliefs and lifestyle behaviors that
may impact health.
While the African immigrant population has grown
exponentially, few studies have examined the health
16 Journal of Nursing Scholarship, 2015; 47:1, 16–24.
C© 2014 Sigma Theta Tau International
Turk et al. Using Photovoice With Nigerian Immigrants
of African-born residents in the United States (US),
including the impact of acculturation on diet and phys-
ical activity. The majority of immigrant health research
has focused on Hispanic and Asian populations and sug-
gests that, generally, these immigrant groups are health-
ier than native-born Americans (Barrington, Baquero, &
Borrell, 2010; Singh, Siahpush, & Hiatt, 2011). Limited
evidence also shows that African immigrants tend to be
healthier than US-born Whites and African Americans
(Read, Emerson, & Tarlov, 2005; Singh & Hiatt, 2006;
Singh & Miller, 2004). Studies on dietary patterns in
groups of immigrant populations show that traditional
diets are healthier than the nontraditional diets that
have evolved with acculturation (Delisle, 2010; Desilets,
Rivard, Shatenstein, & Delisle, 2007). Yet, immigrants
may face barriers in maintaining healthy native diets or
acquiring healthy physical activity habits in their new

countries. Among 5,230 immigrants to the US, 79% re-
ported being physically inactive (Koya & Egede, 2007),
and only 38% of a sample of African immigrants to the
Netherlands said they had engaged in physical activity
in the previous month (Beune, Haafkens, Agyemang, &
Bindels, 2010).
US national data systems used in monitoring health,
mortality, and disease patterns do not identify Africans
in the US as a separate ethnic group, and do not rou-
tinely report and analyze health data by immigrant sta-
tus (Singh & Hiatt, 2006; Singh & Miller, 2004; Singh,
Rodriguez-Lainz, & Kogan, 2013). Thus, data for African-
born immigrants are often entangled with data for
African Americans. An analysis of National Health Inter-
view Survey data showed that 58.4% of African adult im-
migrants were either overweight or obese in 2002 after
residing in the US for 15 or more years (Koya & Egede,
2007). Current statistics of Black US residents, including
persons born in the US or elsewhere, indicate that 54%
and 38% of Black female and male adults, respectively,
are either overweight or obese compared to 33% and
34% of White female and male adults (American Heart
Association Statistics Committee & Stroke Statistics Sub-
committee, 2014). While diet and activity are key deter-
minants of weight, an established contributor to health,
little is known about African immigrants’ perceptions and
practices around healthy eating and physical activity as
they relate to residing in the US.
Photovoice, in which participants use photographs to
describe their health and life experiences, is one method
that has been used as a health-promoting strategy (Wang
& Burris, 1997; Wang & Redwood-Jones, 2001). Initially
originated by Wang and Burris (1997) to document the
everyday lives of women in rural villages of China, Pho-

tovoice is a grassroots approach of community-engaged
research that assists people in identifying the strengths
and issues of their community through photography. The
Photovoice approach has been used previously with im-
migrant groups such as Latino, Chinese, Korean, and
Vietnamese immigrants to learn about topics such as hu-
man immunodeficiency virus prevention, family plan-
ning, mental and cardiovascular health, and the influence
of immigration (Fitzpatrick et al., 2009; Garcia & Saewye,
2007; Rhodes & Hergenrather, 2007; Schwartz, Sable,
Dannerbeck, & Campbell, 2007; Streng et al., 2004). Pho-
tovoice can provide Nigerian African immigrants the op-
portunity to express their ideas about eating habits and
physical activity within the context of their daily lives in
the US.
Purpose
The purposes of this study were to (a) explore the be-
liefs, perceptions, and practices of Nigerian immigrants
regarding healthy eating and physical activity behaviors
while living in the US; (b) assess the influence of cultural
beliefs of Nigerian immigrants on eating and physical ac-
tivity behaviors after migration to the US; (c) describe the
role that healthcare providers can play in helping to pro-
mote healthy eating and physical activity behaviors for
Nigerian immigrants; and (d) evaluate the acceptability,
feasibility, and efficacy of using Photovoice as a technique
to collect data on the perceptions and practices of Nige-
rian immigrants.
Methods
Design

A qualitative visual ethnography design using Pho-
tovoice was employed for this study, and two of the goals
of Photovoice identified by Wang and Burris (1997) were
highlighted: (a) encouragement of individuals to record
their community’s strengths and concerns and (b) fa-
cilitation of critical dialogue through group discussions
about photos taken by the participants. The Photovoice
method includes a four-step process of discovery and en-
gagement. The first step is community training regarding
the process. Three additional steps include (a) selecting
the photos that most accurately reflect the community
and culture; (b) contextualizing the data, which is telling
stories about what the photos mean; and (c) summariz-
ing the data by identifying themes or emerging theories
(Wang & Burris, 1997). Photos taken by the participants
are the principal medium by which viewpoints, percep-
tions, and recommendations develop. Using the photos
as the impetus for discussion via focus groups, this
methodology allows for the collection of rich, in-depth
Journal of Nursing Scholarship, 2015; 47:1, 16–24. 17
Using Photovoice With Nigerian Immigrants Turk et al.
data, possibly not attainable through observations or in-
terview alone.
Setting
Two focus group meetings were held in October and
November of 2013 at a Christian church attended pri-
marily by Nigerian immigrants in an urban area of
Western Pennsylvania. The focus groups were held im-

mediately following the religious service in a private
room in the church hall. A preliminary study conducted
with a community advisory committee from the church
to learn about the community’s health issues, needs, and
concerns revealed a concern about obesity among the im-
migrant group (unpublished data). Thus, we continued
working with this community to learn about their views
on healthy eating and activity in the US.
Participants
Individuals were eligible to participate if they were im-
migrants to the US from Nigeria, at least 18 years old, and
able to read and write in English. Participants also needed
to be able to use the digital camera we provided to take
photos of what they perceived as unhealthy and healthy
eating and activity. Recruitment was facilitated by a re-
search team member of Nigerian descent who had estab-
lished connections with community gatekeepers. We also
utilized the snowball method, in which word of mouth is
utilized, and participants referred to the study other in-
dividuals who might be interested (Munhall, 2011). We
recruited 13 participants.
Procedures
Prior to any study activities, institutional review board
approval was obtained from the university where the
principal investigator is employed. During our first re-
cruitment meeting at the church, the study was explained
to interested individuals, and written informed consent
was obtained. We returned to the church in 2 weeks to
distribute the digital cameras, demonstrate how to use
the cameras, and explain to the participants what they
needed to photograph for the study. We also discussed
potential issues related to using cameras, such as respect-

ing privacy and asking for permission to take someone’s
picture. We instructed participants to take photos for the
next 2 weeks of what they perceived as unhealthy eating
and physical activity. In order to explore the total per-
spective of what was seen as healthy, we also gathered
data about perceptions of what is unhealthy to provide
contrasting ideas. Participants were told they could take
as many photos as they liked, but they would need to
select the top four photos that most accurately reflected
their perceptions of what is unhealthy eating and activity.
In order to facilitate the discussion of each participant’s
pictures at the focus group meetings, it was necessary that
they only select their top four pictures to discuss. A brief
demographic questionnaire was completed by all partici-
pants at this time.
Held 2 weeks later, the next meeting was a focus group
to discuss the photos of unhealthy eating and activity.
Participants were informed that the meeting would be
audiotaped but that their responses would remain con-
fidential. Each participant’s four photos were projected
onto the wall for everyone to view, and each person dis-
cussed their photos with the group. At the end of the first
focus group, which lasted approximately 80 min, partici-
pants were told to take photos of healthy eating and ac-
tivity, and select their top four pictures to discuss when
they returned for another group meeting in 2 weeks.
The second focus group was focused on a discussion
of what the participants perceived as healthy eating and
physical activity and was facilitated as described in the
preceding paragraph. This second focus group lasted ap-
proximately 90 min. Both focus group sessions were au-
diotaped and transcribed verbatim. Healthy snacks were
provided at all meetings, and participants were permitted

to keep the digital camera to compensate them for their
time.
Data Collection
The day before each scheduled focus group meeting,
participants selected four photos that most accurately re-
flected their perceptions of what is unhealthy and what
is healthy, and emailed these photos to the principal in-
vestigator. The research assistant then compiled all the
photos in a PowerPoint (Microsoft Corp., Redmond, WA,
USA) presentation with a slide for each participant’s pho-
tos for display at the meeting. The discussion during
each focus group was facilitated by the authors using a
semistructured interview guide following the pneumonic
SHOWeD to encourage description about the photos, as
is consistent with the Photovoice methodology (Wang
& Burris, 1997). The interview guide included the fol-
lowing questions: (a) What do you See here? (b) What
is really Happening here? (c) How does this relate to
Our lives? (d) Why does this situation exist? (e) What
can we Do about it? We also explored with the partici-
pants what made a food or activity healthy or unhealthy,
whether there were ways to improve the healthiness of
the food, and what healthcare providers might do to pro-
mote healthy eating and activity for Nigerian immigrants.
At least two researchers and a research assistant were
present for each meeting. Two members of the research

team who were of Nigerian descent were present for all
meetings. In order to capture the dynamics of the set-
ting, group, and discussion, the research assistant took
observational field notes. The participants all discussed
their photos individually, and additional input and de-
scription were provided by other group members for each
person’s photos. The photos were all of high quality,
and only one male participant’s photos were not view-
able by the other participants at the focus group that fo-
cused on healthy eating and activity. He did, however,
remember his photos and described them for the group.
Open-ended questions and probes were also used to help
participants express their ideas, attitudes, feelings, and
perceptions about healthy and unhealthy eating and ac-
tivity in the US.
Data Analysis
Transcribed interviews and photos were uploaded to
the NVivo 10 qualitative data software management
system (QSR International, 2013). Transcripts and field
notes were read and re-read by two researchers, and
the analysis followed Leininger’s four phases of quali-
tative data analysis (Leininger, 1991): (a) collecting and
documenting raw data, (b) identifying descriptors and
categories, (c) identifying patterns and initiating contex-
tual analysis, and (d) identifying themes and theoreti-
cal formulations. Phase one consisted of collecting the
data, field notes, observations, and initial analysis. Phase
two focused on the identification of categories; data were
coded according to the domains of inquiry and specific
aims, and 18 categories emerged. In the third phase, the
researchers searched for common patterns via contextual
analysis; data were scrutinized to discover saturation of
ideas, and seven patterns emerged from the categories.

During the final phase, the researchers looked for ma-
jor themes and recommendations from the data, and four
themes emerged. See Table 1 for the categories, patterns,
and themes. Two investigators analyzed transcripts, field
notes, and photos individually and then together, dis-
cussing their analysis and coding choices until consensus
was reached. Analytic memos were maintained as an au-
dit trail for data collection and analysis decisions.
Results
Thirteen Nigerian immigrants agreed to participate,
and 11 participants were present at each focus group
meeting. Participants ranged in age from 27 to 57 years,
were mostly female (92%), and were employed outside
of the home (62%). Everyone had some college educa-
tion. The range of time participants had lived in the US
was between 9 months and 30 years. Most participants
considered English to be their primary language (77%);
one participant each stated Yoruba, Igbo, or Kanuri was
his or her primary language. Participants reported being
part of the Yoruba, Bini, Igbo, or Kanuri ethnic groups.
See Table 2 for the participant characteristics.
Eating and Activity Themes
Four overarching themes emerged from the data: Mod-
eration is healthy, Nigerian ways of living are healthy, ac-
quiring American ways is unhealthy, and cultural context
is important to promote healthy behaviors. These themes
captured the perceptions that the participants had about
healthy and unhealthy eating habits and physical activ-
ity in the context of their daily lives within the US. Al-
though we asked participants to photograph and discuss
both eating behaviors and physical activity, the bulk of

their photos and comments focused on eating habits and
cooking practices.
Moderation is healthy is the first theme that
emerged. This theme encompasses the idea that eating
and activity behaviors should not be done to excess in or-
der to remain healthy. Several participants spoke about
the importance of controlling portion sizes. One woman
stated, “I mean, it’s all about portion. I remember my
mom, when she was alive, she was a nurse, and in the
house we could have a small bowl, and no matter what
you want to eat, it has to fit into that bowl.” Another
woman conveyed that while portion size is important,
the taste of foods is important as well; she stated, “Pro-
portion is everything. I’m not going to finish a whole
bowl [of rice]. I’m just going to take a bit. But at the
same time, I’m not going to not eat doughnuts if I feel like
eating doughnuts.” For her, eating foods like doughnuts
could still be seen as healthy if the food was consumed in
moderation. An excessive amount of watching television
and sitting was identified as unhealthy by the statements,
“. . . for unhealthy activity, TV, too much TV,” and “sitting
and studying is unhealthy activity . . . I’m sitting down.”
Another aspect of the moderation is healthy theme re-
ferred to the timing of meals. Eating too late at night
or eating foods that were considered “heavy” late in
the evening was considered unhealthy. This notion was
demonstrated by one woman’s statement, “I know with
our own food too, the time of the day, you can’t eat
pounded yam at 9:00 p.m., and go to bed . . . you’re not
doing anything. It’s just going to sit in there.” Another
woman reinforced this idea with the comment, “We eat
the solid food in the afternoon; we don’t eat solid food at
night.” Eating heavier foods during the day and not eat-
ing at night was consistent with healthier eating habits.

Nigerian ways of living are healthy theme referred
to the participants’ perceptions that their traditional foods
Using Photovoice With Nigerian Immigrants Turk et al.
Table 1. Categories, Patterns, and Subsequent Themes That
Emerged From the Data Analysis
Categories Patterns Themes
Children’s preferences Generational differences in food choices
Moderation is healthy
Choices Becoming unhealthy in the United States Nigerian ways
of living are healthy
Cooking it healthy Preference for Nigerian food as healthy
Acquiring American ways is unhealthy
Cultural influence Seeing overweight/obesity as economic
Cultural context is important to promote healthy behaviors
Family eating Role for health care in promoting health
Fast food/convenience food Viewing American food as
unhealthy
Food staples
Good for children

Healthcare provider input
Healthy activity
Healthy eating
Moderation
Nigerian food
Substitutions for traditional ingredients
Taste is important
Timing of meals
Unhealthy activity
Unhealthy cooking
and activities were healthy. The majority of the photos
of healthy foods we received were Nigerian dishes, al-
though some photos were of items such as fresh fruits,
steamed vegetables, and water. In describing a Nigerian
food, pounded yam, one woman stated, “It gives us car-
bohydrate because that gives us energy for our body
building.” One woman’s photo of a bean dish was in-
cluded in the healthy foods, and she stated, “That is
actually cooked beans . . . what I do is I cut the plan-
tains and I cook it with the beans so, I don’t have to fry
these. . . .” Everyday physical activity common in their
native country was seen as healthy, for example, “In
Nigeria, we get our activities mostly by walking. It’s not
like people have cabs like here.” Although three partici-
pants discussed engaging in scheduled exercise, most par-

ticipants described incorporating everyday activities as a
means of getting enough physical activity; one woman
noted,
If I go to the mall, I don’t park close to the store. I like
parking far away to get exercise. I don’t go to the gym,
but I like to get my exercise, so I don’t park too close.
Another woman indicated that her household chores
were her physical activity. “I have the leaves and the tools
to blow the leaves, and this is the only kind of exercise
that I do.”
While Nigerian ways of living were mainly seen as
healthy, many participants still recognized that some
Nigerian dishes were not as healthy as they could be
and described healthier cooking adaptations. For ex-
ample, plantains are commonly deep fried, and it was
noted,
Table 2. Participant Characteristics (N = 13)
Demographic characteristic M (SD)
Age (years) 34 (8.9)
Number of children 1.7 (1.7)
Number of people living in household 3.6 (1.6)
Years lived in the United States 10.1 (7.8)
n (%)
Gender (women) 12 (93%)

Employed outside the home 8 (62%)
Level of education
Some college or associate’s degree 6 (46.2%)
Baccalaureate degree 3 (23.1%)
Master’s or doctoral degree 4 (30.7%)
Marital status
Married 12 (93%)
Widowed 1 (7%)
Annual household incomea
<$20,000/year 2 (15.3%)
$20,001–$50,000/year 4 (30.7%)
>$50,000/year 5 (38.4%)
aTwo participants did not report income.
There was one of the questions about plantains and
how they’re not exactly healthy to fry, so I put in an
example of how I bake them . . . and it tastes very close
to the fried ones, so that’s nice.
A male participant discussed preparing foods with little
to no oil, such as, “I’ve learned to completely stay away
from oil. I use a bottle of oil a year.” Others discussed how
Nigerian meat dishes are cooked and served in a broth
but that care needed to be taken to remove additional fat,

for example,
I was talking about the broth that is overnight in the
fridge . . . a portion of this exposed will have fat on top
of the broth. You just have to skim the broth. Some of
this fat has to come off.
Yet, some participants were reluctant to choose healthier
options for cooking, and one woman commented about a
traditional vegetable stew, “You have to use a little bit of
palm oil for taste. If you take out all the fat, what else do
you have for taste?”
Acquiring American ways was the third theme that
emerged from the data and incorporates perceptions that
many foods, activities, and behaviors common in the
US are unhealthy. Related to fast food, several photos
were described, including, “This one is the pizza picture.
We can see it dripping in oil.” Another woman said, “I
count everything fast food as unhealthy. I don’t allow my
children to eat it.” Several participants stated that their
children preferred unhealthy American food, but that
they tried to balance what they served their children, for
example, “I try to give them salad to eat. . . . So I make
sure I give them a lot, so then for their main meal, they’ll
just eat less of the unhealthy meal.” When asked about
whether there were individuals in their Nigerian commu-
nity in the US who were obese, most participants said that
there were, and one woman noted, “When you go into

a different country you throw your culture away. . . .”
Another commented on the hectic lifestyle in the US:
“When you’re going to work and you can’t cook, and you
don’t have time, it’s a problem.” One male participant
described the Nigerian immigrant’s lifestyle in the US by
saying, “I realize that we work a lot, and it’s a killer. I just
feel that for Africans here in this country, they are work-
ing two jobs, three jobs, going to school, stress is killing
people. . . .” Because of this busy lifestyle, participants
talked of quiet time, meditation, and prayer as healthy
activities in the context of their lives in the US. “I can
see that physical activity can be something different, just
keeping still for some cultures. . . .” “Quiet time is usually
like the time that you meditate. . . . When I’m driving, I
use that particular time to take a quick word of prayer. . . .
So I think that helps with my sanity.” Conscious efforts
were needed to cope with the demands of their fast-paced
lifestyle in the US.
Cultural context is important to promote healthy
behaviors, the final theme, referred to what healthcare
providers can do to encourage Nigerian immigrants to
eat healthier and engage in healthy physical activity. Par-
ticipants emphasized the importance of providers taking
time to ask about and learn the foods that Nigerians eat.
One woman stated,
If I’m seeing a doctor here, the doctor doesn’t under-
stand what I’m eating in terms of the African dishes
. . . if I come with what I eat, then you can advise me
on portion control or maybe substitutions for some of
the things.
This need for education from healthcare providers was
expressed by others.

Like teaching Africans how to make healthy meals
. . . people are afraid to step out of their comfort zone
. . . training that would not only teach how to make
meals, but also teach how to get it healthy.
Participants talked about wanting educational activities
within their community setting. “If you can suggest ac-
tivities that we can do, and if you could give us some sug-
gestions of healthy activities we can use for our [women’s
group] meetings. . . .” Others wanted to explore the pos-
sibility of including a gym in the church hall. “What I
was thinking, was like if you can get like a gym here that
would be a way of encouraging people to do the physical
activity. For us, we can’t go to the gym for free.” Par-
ticipants also thought that nurses and other healthcare
providers “should encourage people to do more cooking
at home instead of going to the restaurants.”
Discussion
Never before utilized with Nigerian immigrants, Pho-
tovoice was a valuable method to explore the beliefs,
perceptions, and practices of these participants regard-
ing healthy eating and physical activity behaviors while
living in the US. This methodology was well received
and easily used by the Nigerians in this study. At the
conclusion of the study, we talked with the participants
about their experiences using the digital camera to cap-
ture their perceptions of unhealthy and healthy lifestyle
behaviors since immigration to the US. All participants
expressed that the camera was easy to use, and that they
enjoyed taking photos and discussing their ideas. The
photo-elicited discussions were rich with descriptions of
healthy and unhealthy Nigerian and American foods and
adaptations that could be applied to improve the health-
iness of certain foods. The facilitated group dialogue cov-

ering each participant’s photos ensured that everyone’s
voice was heard, and a diverse range of perspectives
was put forth and considered. Ideas about healthy eating
and activity within the context of their busy lives were
revealed through the interactive dialogue fostered by
the photos.
Little has been published about the health and lifestyle
behaviors of African immigrants to the US. Evidence
supports the idea that African immigrants are healthier,
…
NSG3036 W2 Project
Research Template Name
Cite both articles reviewed in APA style:
***In the template, any direct quotes from the articles needs to
only include the page number.
Week 2 Template
Quantitative Article
Qualitative Article
Summarize the two assigned articles. In a paragraph, describe in
your own words what the study was about and what the
researchers found.

Identify and describe the problem for each article
Identified the purpose statement for each article
Identified hypothesis and/or research questions depending on
the methodology used in the articles.
After analyzing, discuss
each article’s significance to nursing practice.
Identify two details to support the study being quantitative or
qualitative

January-February 2018 • Vol. 27No. 138Hillary Jenson, BSN.docx

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