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1. The Future of Nursing Theory Discussion
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PAPERS ON The Future of Nursing Theory DiscussionThis assignment is a discussion board
Post which requires the use of APA 7 for reference and citation. I will be attaching the
documents needed for this assignment. This assignment is the concluding part of the
semester work hence information used prior in the semester is needed to answer some of
the questions.The Future of Nursing Theory
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PreviewAssignment Instructions Discussion Board: The focus of this assignment is to
prompt you to reflect on your learning this term. You will demonstrate your understanding
of the interplay among research, theory, and practice through your critical thinking
evidenced in your responses to the discussion board items. You will also investigate
examples of the globalization of nursing. 1. Describe what the following quote means to you.
“Theory without practice is empty and practice without theory is blind” (*Cross, 1981, p.
110). 2. Explore the Sigma website. o Based on your exploration of the Sigma Theta Tau
International website, provide 3 specific examples of the globalization of nursing. At least
one example must include an example of an internationally written article from the most
recent issue of the Journal of Nursing Scholarship. o You can access this journal from the
Sigma website.
(https://sigmapubs.onlinelibrary.wiley.com/journal/15475069#pane01cbe741-499a-
4611-874e-1061f1f4679e01 (Links to an external site.)). ▪ It will only give you the title of
the articles in the journal and abstracts. If you want to read the articles, you will need to go
to the online library and look at them there. 3. Share the three most important concepts that
you learned this 7-week term. 4. The Future of Nursing Theory DiscussionWhat were the
two most challenging activities for you confronted in this course? What suggestions do you
have related to addressing those challenges? *Cross, P. (1981). Adults as learners.
Washington, DC: Jossey-Bass. Liver Health Literacy and Health Status Among Adults With
Hepatitis C: Implications for the Nursing Profession as Part of the 2030 Global Elimination
Goal Yu-Chih Lin, MD1, Wen-Nan Chiu, MD2, Te-Sheng Chang, MD, PhD3, Tung-Jung Huang,
MD, PhD4, & Mei-Yen Chen, PhD, RN5 1 Department of Family Medicine, Chang Gung
Memorial Hospital, Yunlin, Taiwan 2 Department of Hepato-Gastroenterology, Chang Gung
Memorial Hospital, Yunlin, Taiwan 3 Division of Gastroenterology and Hepatology,
Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, and
Assistant Professor, College of Medicine, Chang Gung University, Taoyuan, Taiwan 4

2. Department of Pulmonary Disease and Critical Care, Chang Gung Memorial Hospital, Yunlin,
Taiwan, and Department of Respiratory Care, Chang Gung University of Science and
Technology, Chiayi, Taiwan 5 Department of Nursing, Chang Gung University of Science and
Technology, Chiayi, Taiwan, and Department of Nursing, Chang Gung University, Taoyuan,
Taiwan, and Research Fellow, Department of Cardiology, Chang Gung Memorial Hospital,
Yunlin, Taiwan Key words Direct-acting antiviral therapy, hepatitis C virus rural, liver
health literacy, prevalence, unhealthy lifestyle Correspondence Professor Mei-Yen Chen, No.
2, Chiapu Rd. West Sec., Putz City, Chiayi County 61363, Taiwan, ROC. E-mail:
meiyen@mail.cgust.edu.tw Accepted October 21, 2019 doi:10.1111/jnu.12533 Abstract
Purpose: To explore the prevalence of hepatitis C virus (HCV) infection as well as the levels
of liver health literacy and association with the health status of people with HCV through
the nurse-led community health development goal of global elimination. Methods: A
community-based, cross-sectional study was conducted between July 2018 and June 2019
in coastal Western Yunlin County, Taiwan. This study was conducted at five townships, and
serum HCV antibody (antiHCV) screening was used for the identification of potentially
infected people by a collaborating local hospital. Results: Of the 1,963 adults from rural
areas enrolled in this study, 321 (16.4%) were anti-HCV positive, 237 (73.8%) reported that
they were unaware of their HCV positivity, and none of them were provided information on
direct-acting antiviral agent therapy. The levels of anti-HCV positivity were higher among
female patients (p < .05), elderly people (p < .001), those with a low education level (p <
.001), and those from the Sihu Township within Yunlin County (p < .001). Participants with
antiHCV positivity tended to have lower intakes of vegetables (p < .01) and fruit (p < .05), a
greater number of comorbidities (p < .05), as well as a greater incidence of abnormal liver
(p < .001) and renal function (p < .001) compared to those with anti-HCV negativity.
Multivariable linear regression analysis showed that the presence of HCV infection and a
greater number of metabolic syndrome components were associated with poor liver and
renal function. Conclusions: The Future of Nursing Theory DiscussionThese findings
showed a high prevalence of HCV infection among adults living in rural areas, who had low
literacy levels on hepatitis, unhealthy lifestyles, and abnormal liver and renal function.
Clinical Relevance: Clinicians and primary healthcare providers should initiate efforts to
increase the levels of liver health literacy by increasing the accessibility to infection
confirmation tests and reducing the number of barriers to the reception of antiviral
treatment. Hepatitis C virus (HCV) is a blood-borne virus, and its infection has emerged as a
global health concern, with an estimated prevalence of 3% (2.3–3.5 million 128 people) in
the United States and 71 million people worldwide (Rosenberg et al., 2018; World Health
Organization [WHO], 2019). While for some people Journal of Nursing Scholarship, 2020;
52:2, 128–135. © 2019 Sigma Theta Tau International Hepatitis C Elimination Lin et al.
hepatitis C is a short-term illness, for 70% to 85% of those with HCV infection, the condition
is longterm and chronic. The WHO (2019) estimated that each year, approximately 399,000
people die of hepatitis C globally, predominantly from the related cirrhosis and
hepatocellular carcinoma (HCC). Recent strong evidence suggests that HCV infection causes
a number of important extrahepatic complications, such as vasculitis, systemic
atherosclerosis and coronary artery disease, chronic kidney or end-stage renal disease, type

3. 2 diabetes, and all-cause mortality (Ambrosino et al., 2016; Fabrizi, Dixit, & Messa, 2019;
Negro et al., 2015; Petruzziello, Marigliano, Loquercio, Cozzolino, & Cacciapuoti, 2016;
Younossi Papatheodoridis, & Cacoub, 2018; Younossi et al., 2016). This may be because HCV
progresses from persistent hepatic inflammation, steatosis, and fibrosis to cirrhosis and
HCC (Westbrook & Dusheiko, 2014). HCV infection is diagnosed in two steps: screening for
anti-HCV antibodies is performed with a serological test, and if the result is positive, a
nucleic acid test for HCV ribonucleic acid (RNA) is performed to confirm chronic infection
(Castro et al., 2018; WHO, 2019). Previously, patients with hepatitis C were treated with
interferon-based regimens, which are associated with frequent adverse effects, suboptimal
response rates, and long treatment durations of up to 48 weeks (Bickerstaff, 2015).
Commonly reported side effects, including influenza-like and neuropsychiatric symptoms,
were observed to have led to reductions in the number of those undergoing treatment for
HCV infection (Chiu, Huang, Lin, & Chen, 2017). Fortunately, in recent years, the treatment
of HCV infection has been revolutionized with the introduction of pangenotypic, interferon-
and ribavirin-free regimens, which are associated with high cure rates and a low side effect
profile (Burki 2019; Centers for Disease Control and Prevention [CDC], 2019; Younossi et
al., 2018). The WHO (2019) reported that HCV infection can be completely cured with
direct-acting antiviral agents (DAAs), which are highly safe and can be administered over a
simple 12-week course (CDC, 2019; Ward & Mermin, 2015). Therefore, the WHO (2019)
aims to eliminate HCV infection by 2030, worldwide. In Taiwan, an estimated 400,000 to
700,000 people have chronic hepatitis C infection. According to official reports, the average
HCV infection prevalence rate is 4.2%, at least 7.3% of whom were observed to reside in
coastal rural areas, most of whom were older, and 76% of whom were infected as a
consequence of unsafe medical devices use a few decades ago (National Health Insurance,
[NHI], 2019; Taiwan Medical Association, 2018). However, only a few of those Journal of
Nursing Scholarship, 2020; 52:2, 128–135. © 2019 Sigma Theta Tau International people
had access to DAA treatment. Hence, the Taiwan Hepatitis C Policy Guideline 2018–2025
was approved and published at the beginning of 2019. The Taiwanese government provided
US$1.7 billion for the control of hepatitis C in January 2019 (NHI, 2019). This aimed to
reduce the number of barriers to the reception of care, screening strategies, continuum of
care, and preventive measures for high-risk populations, thereby improving liver health
literacy regarding preventing new infections and re-infections, and managing liver disease.
With this, outcome evaluation of policy and intervention development becomes more
effective (Chen, 2019). Burki (2019) reiterated that drugs alone are not enough to eliminate
HCV infection, and countermeasures such as screening and accessibility to harm reduction
services are also needed. The Future of Nursing Theory DiscussionUnfortunately, many
people in rural areas are unaware that they have HCV infection, and of the exact treatment
resources that are available. Unhealthy lifestyles, characterized by cigarette smoking,
inactivity, and low intakes of vegetables and fruit, are associated with some cancers and
chronic diseases, as a consequence of vascular disruption, platelet activation, oxidation and
inflammation, and endothelial dysfunction (Fan, Huang, Jane, & Chen, 2015; Lin et al., 2018).
In Taiwan, cardiometabolic-related diseases, including diabetes, stroke, hypertension, and
heart disease, are the top 10 most commonly reported causes of death (Health Promotion

4. Administration, 2019). Community health nurses are responsible for the provision of
frontline care as well as adequate information to residents with HCV infection and their
families, and transferring them for the reception of DAA treatment (Shiffman & Gunn,
2017). However, few nursing studies have focused on community-based screening of anti-
HCV antibodies, further HCV RNA confirmation in endemic rural areas, and the association
between health-related behaviors and health status in adults with HCV infection. Methods
Design, Sample, and Setting This study is the first phase of a nurse-led community health
development program that is being established to reduce the rates of HCV infection in
endemic rural areas. Working with a local hospital, the research team held annual
community health screenings between July 2018 and March 2019 in coastal southern
Taiwan. The inclusion criteria were (a) area of residence being in one of five designated
townships in Yunlin County and age 20 years or older, 129 Hepatitis C Elimination (b)
ability to sign an informed consent form, (c) ability to walk to the community centers, and
(d) ability to complete the questionnaire. Those who are unable to answer questions or
have any limitations in cognition were excluded from this study. Procedure and Ethical
Considerations We did not conduct the research until the institutional ethical committee
review board had approved the study (No. 201800428B0). The local hospital and the leader
of each community activity center used broadcasting material on free health screening to
invite people with HCV infection and their family members to walk to a community center
located in each of 30 villages, on a Monday or Tuesday morning every week during the
study period. The purpose of the study was described by the research assistants to all
participants, such as supplying information on the risks of HCV and liver cancer, describing
the procedure for drawing blood samples after an overnight fast of 8 hr from midnight, and
posing health-related questions before study initiation. Measurements Demographic
characteristics included sex, age, education level, serum anti-HCV antibody status (positive
or negative), and comorbidities (participants were asked to answer if they had been
diagnosed with diabetes mellitus, hypertension, heart disease, or other chronic conditions
by a doctor). Cardiometabolic risk factors and liver and renal function. Cardiometabolic risk
factors were determined by the national standard (HPA, 2019), including (a) waist
circumference > 90/80 cm for male or female participants, respectively; (b) systolic or
diastolic blood pressure > 130/85 mmHg; (c) high-density lipoprotein-cholesterol (HDL-C)
level < 40/50 mg/dL for male or female participants, respectively; (d) fasting blood glucose
level > 100 mg/dL; and (e) triglyceride level > 150 mg/dL; metabolic syndrome (MetS) was
defined as the presence of three or more of these risk factors. (f) Glutamic-oxalocetic
transaminase (GOT) and glutamic-pyruvic transaminase (GPT) levels were used to detect
liver inflammation status, and (g) the estimated glomerular filtration rate (eGFR) was
indicative of renal health. Liver health literacy and healthy lifestyle. Participants were asked
to answer if they (a) were aware or unaware of their HCV infection status; (b) had received
screening for hepatitis; and (c) were informed of the new free drugs available for hepatitis
treatment. The 130 Lin et al. participants’ lifestyle status, pertaining to liver health, was
determined as previously described (HPA, 2019; Wang, Li, Chang, & Chen, 2015).
Participants were asked to respond to the following five behavior questions with
“never/seldom” or “usually/always”: (a) Vegetable intake: “Do you consume three portions

5. of vegetables every day?” (b) Fruit intake: “Do you consume two portions of fruit per day?
(c) Water intake: “Do you drink 1,500 mL of water per day?” (d) Regular exercise: The
Future of Nursing Theory Discussion“Do you engage in exercise for 30 minutes, at least
three times per week?” (e) Substance use was determined according to participants’ current
smoking, betel nut chewing, or alcohol intake status (currently, or never, or ceased). Data
Analysis Data analyses were conducted using SPSS version 25 (IBM Corp., Armonk, NY,
USA). A chi-square test and independent-samples t test were used to explore the categorical
or continuous variables of the participant’s demographic characteristics. To investigate the
associations between anti-HCV status and liver and renal health, multivariable linear
regression analyses were performed, adjusting for demographic characteristics. All tests
were two-tailed, and p < .05 was considered statistically significant. No multiple testing
(multiplicity) adjustments were made in this study. Results A total of 1,963 adults were
enrolled, of whom 321 (16.4%) were serum anti-HCV positive. The prevalence of anti-HCV
positivity was higher in the female participants (Figure 1A). The anti-HCV positivity rate
was significantly different across different regions (Figure 1B). The participants’ mean age
was 65.3 years (SD, 14.1 years; range, 20–97 years). The average education level was
elementary school (mean, 5.8 years; SD, 5.2 years). More than half of the participants
reported having a vegetable intake level of at least three portions per day, and 33.7%
exercised regularly. As for substance use, smoking was the most commonly observed habit
(17%), followed by betel nut chewing (7.2%) and alcohol intake (6.3%). Hypertension was
the most prevalent comorbidity (30%), followed by diabetes (15.8%) and heart disease
(11%). MetS was highly prevalent (45.9%), with the mean number of MetS components at
2.4 (SD, 1.4). Data on the participants’ lipid profile and liver and renal function are listed in
Table 1. Compared to the anti-HCV-negative participants, those with anti-HCV positivity
were older, tended to be Journal of Nursing Scholarship, 2020; 52:2, 128–135. © 2019
Sigma Theta Tau International Hepatitis C Elimination (a) 20 Proportion (%) Lin et al. 15
with higher levels of GOT (regression coefficient [B], 9.2; 95% confidence interval [CI], 7.3
to 11.1) and GPT (B, 11.1; 95% CI, 8.8 to 13.4) and lower eGFR values (B, -3.0; 95% CI, -5.5
to -0.6). In addition, the presence of a greater number of MetS components was associated
with higher levels of GOT (B, 0.6; 95% CI, 0.1 to 1.1) and GPT (B, 2.3; 95% CI, 1.7 to 3.0), and
lower eGFR values (B, -2.3; 95% CI, -2.9 to -1.6). P = 0.031 10 5 0 17.7 14 Female Male Sex
Proportion (%) (b) 30 Discussion P < 0.001 25 20 15 10 5 0 12.3 13.8 26.6 8.8 22.2 A B C D
E Region Figure 1. Prevalence of anti-hepatitis C virus positive according to sex (A) and
region (B). A: Dongshi Township (n = 470); B: Lunbei Township (n = 643); C: Sihu Township
(n = 425); D: Baozhong Township (n = 249); E: Tacheng Township (n = 176). female, and
had a lower education level, poor dietary behaviors, and a high prevalence of comorbid
diseases. As for cardiometabolic risks, participants who were anti-HCV positive had
significantly higher abnormal HDL-C levels (40.5%, p < .01) and lower triglyceride levels (p
< .01). However, the prevalence of MetS was similar in both groups (48.6% vs. 45.4%, p =
.289). In terms of liver and renal function, participants with anti-HCV positivity had higher
levels of both GOT and GPT and a lower eGFR (see Table 1). Table 2 shows that of the 321
anti-HCV-positive participants, 237 (73.8%) reported being unaware of having HCV
infection. Participants who were aware of having HCV infection were younger (p < .001),

6. had a higher education level (p < .01), and tended to have higher alcohol intake levels (p <
.05). Almost all the participants (n = 318; 99%) reported that they had undergone health
screening within the past 5 years, but many of them did not know their health check results.
In addition, none of the participants had heard of free oral drugs for hepatitis treatment.
Multivariate linear regression analyses with adjustment for demographic characteristics, as
shown in Table 3, demonstrated that anti-HCV positivity was associated Journal of Nursing
Scholarship, 2020; 52:2, 128–135. © 2019 Sigma Theta Tau International The purpose of
this study was to explore the prevalence of HCV infection and liver health literacy levels
among people with HCV, and their association with health status in coastal southern
Taiwan. The study yielded three important findings. First, the HCV infection prevalence was
high and most people with the infection were unaware of their infection status. Second,
participants with anti-HCV positivity tended to engage in unhealthy lifestyle habits and had
a greater number of comorbidities with cardiometabolic disease. Third, a high prevalence of
MetS was observed. Anti-HCV positivity and cardiometabolic risk were shown to be
associated with poor liver and renal function. A high prevalence of anti-HCV positivity in
coastal southern areas was found in this study; the value that was obtained was higher than
that stated in the official national report (2%–4%) (Taiwan Medical Association, 2018). The
most commonly cited cause of infection was use of unsafe medical devices many years
previously, especially in rural areas with limited health resources (NHI, 2019). For instance,
unqualified doctors without certified physician’s licenses have been practicing in the
western coastal areas for decades. The medical devices that they used were not properly
disinfected or discarded, which caused, among other things, HCV infection in these patients.
The elders in the rural areas preferred to see these unqualified doctors over going to the
hospital due to the cheaper medical expenses and more convenient transportation related
to the former. Further, 73.8% of the participants with anti-HCV positivity (n = 237) were
unaware of their infection status. This result echoes recent big data obtained from Taiwan
Liver Foundation’s nationwide community outreach program (N = 50,909), which showed
that, of the 41% of people who had undergone hepatitis screening, only 60.8% knew their
results; even among those who were aware of their condition, few followed up with a
healthcare pr …The Future of Nursing Theory Discussion