Angela Nannini

University of Massachusetts Lowell, Lowell, Massachusetts, United States

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Publications (21)42.06 Total impact

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    ABSTRACT: Revisiting scope of practice (SOP) policies for nurse practitioners (NPs) is necessary in the evolving primary care environment with goals to provide timely access, improve quality, and contain cost. This study utilized qualitative descriptive design to investigate NP roles and responsibilities as primary care providers (PCPs) in Massachusetts and their perceptions about barriers and facilitators to their SOP. Through purposive sampling, 23 NPs were recruited and they participated in group and individual interviews in spring 2011.The interviews were audio recorded and transcribed. Data were analyzed using Atlas.ti 6.0 software, and content analysis was applied. In addition to NP roles and responsibilities, three themes affecting NP SOP were: regulatory environment; comprehension of NP role; and work environment. NPs take on similar responsibilities as physicians to deliver primary care services; however, the regulatory environment and billing practices, lack of comprehension of the NP role, and challenging work environments limit successful NP practice.
    Policy Politics &amp Nursing Practice 03/2013;
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    ABSTRACT: The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.
    Journal of professional nursing: official journal of the American Association of Colleges of Nursing 03/2013; 29(6):338-349. · 0.76 Impact Factor
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    ABSTRACT: Objective: To compare outcomes from uterine ruptures (UR) among women without versus with a prior cesarean. Method: This case-control study matched on gestational age +/- 1 week and birth year +/- 2 years using a variable numbers of controls (maximum = 4) for each case. All URs in Massachusetts between 1990 and 1998 were identified using ICD-9 codes from linked hospital discharge and birth/fetal death certificate files and confirmed by medical record review. Complete hospitalization records were abstracted. Maternal outcomes were hysterectomy, transfusion, ICU admission, shock, assisted ventilation, and hospital length of stay. Infant outcomes were 5 min Apgar less than 3 or need for ventilation at birth, death, or poor prognosis at discharge. Results: The UR incidence in women without a prior cesarean was 7 per 100,000 births. Of the 49 women without a prior cesarean and a UR, 36 women met study criteria and were matched to 140 controls. Women without a prior cesarean had more severe maternal morbidity (50% vs. 16%) (adj OR 3.28, 95% CI: 1.70, 6.32) with 47% of cases requiring transfusion and 33% requiring ICU admission. Their hospital stays were nearly two days longer. Among their infants, 14% died or had a poor prognosis at discharge compared to 7% of control infants (OR = 2.42, 95% CI 0.94, 6.28). Conclusion: Although UR in a woman without a prior cesarean is uncommon, providers should be prepared for more severe maternal morbidity which may be mitigated by prompt surgical intervention and heightened hemodynamic surveillance.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 09/2012; · 1.36 Impact Factor
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    ABSTRACT: Objective:To describe maternal and perinatal morbidity and mortality associated with uterine rupture (UR) among women with prior cesarean/s, singleton term pregnancies and a trial of labor after cesarean (TOLAC).Study Design:Linked hospital discharge files and birth/fetal death certificates identified potential cases of UR in Massachusetts from 1990 to 1998 with definitive identification by medical record abstraction.Result:Among the 347 identified URs, severe outcomes occurred in 86 cases (25%), in 49 (14%) of mothers and 49 (14%) of infants. Of the infants, 25 were discharged with a good prognosis. Maternal age and interdelivery interval <18 months (relative risk (RR)=1.55; 95% confidence interval (CI): 1.05, 2.31) were associated with a severe outcome. The type of hospital and labor were not associated with the increased risk of a severe outcome.Conclusion:Assuming a 0.7% UR rate among women at term with a TOLAC, the increased rate of severe outcomes related to UR above the baseline risk of elective cesarean is estimated to be 1.3 per 1000 TOLACs.Journal of Perinatology advance online publication, 22 March 2012; doi:10.1038/jp.2012.2.
    Journal of perinatology: official journal of the California Perinatal Association 03/2012; · 1.59 Impact Factor
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    ABSTRACT: To assess the validity of probabilistic linkage (PL) in combining national surveillance data on assisted reproductive technology (ART) with Massachusetts birth and infant death data, for the purpose of monitoring maternal and child health outcomes of ART. A study conducted in 2006 utilized direct identifiers to match Massachusetts birth records with records on ART procedures performed to Massachusetts residents in fertility clinics located in Massachusetts and Rhode Island, achieving a linkage rate of 87.5%. The present study employed PL using the program Link Plus, without access to direct identifiers. The primary linking variables were maternal and infant dates of birth, and plurality. Ancillary variables such as maternal ZIP code and gravidity helped resolve duplicate matches and capture additional matches. PL linked 5,390 (87.8%) of 6,139 deliveries, correctly identifying 96.4% of the matches previously obtained using deterministic linkage methods. PL yielded a high linkage rate with satisfactory validity; this method may be applied in other states to help monitor the maternal and child health outcomes of ART.
    Maternal and Child Health Journal 09/2011; · 2.24 Impact Factor
  • Angela Nannini
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    ABSTRACT: Spring 2010 marked the passage of the Patient Protection and Affordable Care Act; however, soon after this landmark legislation passed, legal and political challenges ensued to change key features of the law. In this environment of proposed changes to transform the U.S. health care system, the Institute of Medicine released its report titled The Future of Nursing: Leading Change, Advancing Health in October 2010. The groundbreaking consensus report calls for a transformation of nursing at practice, education, and leadership levels. This article briefly summarizes findings and key recommendations with an emphasis on areas most relevant to the future of gerontological nursing. In addition, various implementation actions promoted through the Robert Wood Johnson Foundation's Future of Nursing Campaign and the AARP Center to Champion Nursing are discussed to encourage gerontological nurses to participate in current and future debates.
    Journal of Gerontological Nursing 08/2011; 37(9):11-5. · 0.81 Impact Factor
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    ABSTRACT: Mental illness (MI), substance abuse (SA), and intentional injury (II) are known individual risk factors for adverse pregnancy outcomes. Their combined association with preterm birth (PTB) and low birth weight (LBW) remains relatively unexplored. We examined hospital utilization for the co-occurrence of II and MI or SA in pregnant women in Massachusetts and assessed their interactive association with PTB and LBW. This retrospective cohort study used ICD-9 and E-codes reported on linked birth and hospital utilization data to identify MI, SA, and II diagnoses during pregnancy for 176,845 Massachusetts resident women who delivered during 2002-2004. Adjusted odds ratios (OR) for the independent and joint associations of MI, SA, and II on PTB and LBW were calculated. Two thousand two hundred and eight women (1.6%) had a prenatal MI visit, 834 (0.5%) a prenatal SA visit, and 847 (0.5%) a prenatal II visit. Among them 163 women had MI and II visits and 69 had SA and II visits. SA, MI, and II were all significant predictors of LBW and PTB. Women with both SA and II had higher odds of PTB (OR 2.7 95% CI 1.3-5.7) and LBW (OR 5.3 95% CI 3.9-7.3) than women with neither diagnosis. Prenatal MI, SA, and II are risk factors for LBW and PTB. Women with SA and II co-diagnoses have greater risk of LBW and PTB than women with neither diagnosis. Screening, timely diagnosis, and treatment of women with co-occurring morbidities, particularly II and SA, should be incorporated into reproductive and perinatal health programs.
    Maternal and Child Health Journal 06/2011; 16(5):979-88. · 2.24 Impact Factor
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    ABSTRACT: The objectives of this study were to determine risk factors for early (less than 34 weeks gestation) and late (34-36 weeks gestation) preterm singleton birth, by assisted reproductive technology (ART) status. We linked data from Massachusetts birth records and ART records representing singleton live births from 1997 through 2004. Using multinomial regression models, we assessed risk factors for early and late preterm birth by ART status. From 1997 to 2004 in Massachusetts, among non-ART births, risk factors for early and late preterm birth were similar and included women <15 and ≥ 35 years of age, those of non-white race or Hispanic ethnicity, those with ≤ 12 years of education, those with chronic diabetes, those with gestational diabetes, those with gestational hypertension, those who smoked during pregnancy, those who used fertility medications, and those who had not had a previous live birth. Among ART births, risk factors for early and late preterm birth differed and odds of early preterm birth were increased among women with ≤ 12 years of education while odds of late preterm birth were increased among women with gestational diabetes. Odds of both early and late preterm birth were increased among women of non-white race or Hispanic ethnicity and among women with gestational hypertension. Among non-ART births, increased risk for preterm birth was more strongly related to socioeconomic factors than among ART births. Medical conditions were associated with an increased risk for preterm birth regardless of women's ART status. Efforts to prevent preterm births should focus on reducing modifiable risk factors.
    Maternal and Child Health Journal 04/2011; 16(4):807-13. · 2.24 Impact Factor
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    ABSTRACT: To identify risk factors associated with uterine rupture among term pregnancies attempting a vaginal birth after a previous cesarean. A case-control study was done of 348 uterine ruptures in Massachusetts between 1991 and 1998, initially screened by ICD-9 code and confirmed by medical record review, with 424 control women with a trial of labor randomly selected proportional to cases on year of delivery. Multivariable regression was used to estimate odds ratios and 95% confidence intervals. Successful previous vaginal birth decreased risk for uterine rupture, and gestation > 40 weeks and macrosomia increased risk. Oxytocin for induction increased risk, with a slightly lower effect when used for augmentation. Prostaglandin use in conjunction with oxytocin did not have an additive uterine rupture risk. Women using epidural analgesia have an increased uterine rupture risk. Certain labor management practices increase the risk for uterine rupture 2-3 times, although the absolute increase is small from a baseline uterine rupture rate of 0.5% to 1.0-1.5%. The association between epidural analgesia and uterine rupture deserves further study.
    The Journal of reproductive medicine 01/2011; 56(7-8):313-20. · 0.75 Impact Factor
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    ABSTRACT: To clarify the risk of violence for women during pregnancy and the first year postpartum, we examined the timing of hospital visits for assault among a population cohort of women in Massachusetts. Using linked natality and hospital data from 2001 through 2007 for Massachusetts, we examined the timing of hospital (i.e., emergency, inpatient, and observation) visits for maternal assault during seven time periods: the three prenatal trimesters and four three-month postpartum periods. To describe the risk of assault for each of the time periods, we calculated the rate as the number of such visits per 100,000 person-weeks. We used the denominator of 100,000 person-weeks to adjust for variable lengths of gestation and for postpartum periods shortened by subsequent pregnancies. Rates of hospital visits for maternal assault were highest in the first trimester and lowest in the third trimester, with rates of 16.0 and 5.8 per 100,000 person-weeks, respectively. The four postpartum period rates were higher than the third trimester rate but never reached the levels observed in the first and second trimesters. These findings suggest a changing rate for assault visits during each prenatal trimester and postpartum period. In addition, the importance of violence prevention strategies as part of women's health care across the life span and the need for preconception care initiatives are reaffirmed.
    Public Health Reports 01/2011; 126(5):664-8. · 1.42 Impact Factor
  • Angela Nannini, Susan Crocker Houde
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    ABSTRACT: Gerontological nurses who have received education and have experience in conducting systematic reviews may assume a key role in interpreting systematic reviews for policy makers. Systematic reviews offer evidence to determine the best policy and program solutions to a problem. To be successful in translating evidence from systematic reviews, gerontological nurses need to (a) understand the steps of the policy making process and where different kinds of reviews may be used, (b) assess the "technical" literacy and level of interest in gerontological issues of the intended policy maker, and (c) develop and practice skills in policy writing that distill information in policy briefs as well as shorter formats. Gerontological nurses can be powerful advocates for older adults using the systematic review of the literature as an instrument to educate policy makers.
    Journal of Gerontological Nursing 06/2010; 36(6):22-6. · 0.81 Impact Factor
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    ABSTRACT: To evaluate the accuracy of assisted reproductive technology (ART) reporting on the Massachusetts birth certificate and to explore the individual and hospital-level characteristics associated with ART reporting. Validity analysis of population-based data. Live-birth deliveries by Massachusetts-resident mothers during 1997-2000. Live births and delivery mothers. The ART data maintained by the Centers for Disease Control and Prevention were linked with the live birth-infant death records in Massachusetts. Successfully linked records were used as the gold standard for ART-related deliveries in evaluating the validity of the ART information reported on the Massachusetts birth certificate. Sensitivity and specificity. The sensitivity of ART reporting on the birth certificate was 27% and the specificity >99%. Sensitivity of ART reporting was higher among women with multiple deliveries (twins: 32%; triplets+: 43%) and preterm deliveries (36%). During the period evaluated, reporting of ART information on the birth certificate was incomplete, and ART births identified through the birth certificate were a biased sample of the population of ART births. Using delivery hospital data as the sole source of ART information for the standard birth certificate may yield inaccurate information.
    Fertility and sterility 12/2009; 94(5):1657-61. · 3.97 Impact Factor
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    ABSTRACT: Approximately 18% of multiple births in the USA result from assisted reproduction technology (ART). Although many studies comparing ART and naturally conceived twins report no difference in risks for perinatal outcomes, others report slight to moderate positive or protective associations. We selected twin deliveries with and without indication of ART from Massachusetts live birth-infant death records from 1997 to 2000 linked to the US ART surveillance system. The sample was restricted to deliveries by mothers with increased socioeconomic status, private health insurance and intermediate/plus prenatal care use. Our final sample included 1446 and 2729 ART and non-ART twin deliveries, respectively. Odds ratios (OR) for associations between ART and perinatal outcomes were adjusted for maternal demographic factors, smoking, prenatal care and hospital care level. ART twin deliveries were less likely than non-ART to be very preterm (adjusted OR 0.75; 95% confidence interval 0.58-0.97) or include a very low birthweight (<1500 g) infant (0.75; 0.58-0.95) or infant death (0.55; 0.35-0.88). In stratified analyses, these findings were observed among primiparous deliveries, but there were no risk differences among multiparous ART and non-ART twin deliveries. ART treatment was not a risk factor for adverse perinatal outcome, and risks for several outcomes were somewhat lower among ART twin deliveries. Nonetheless, ART is strongly associated with twinning and twins remain a high-risk group, relative to singletons. Promoting singleton gestation in assisted conception is an important strategy for reducing adverse outcomes.
    Human Reproduction 08/2008; 23(8):1941-8. · 4.67 Impact Factor
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    ABSTRACT: Late-preterm infants (34-36 weeks' gestation) account for nearly three quarters of all preterm births in the United States, yet little is known about their morbidity risk. We compared late-preterm and term (37-41 weeks' gestation) infants with and without selected maternal medical conditions and assessed the independent and joint effects of these exposures on newborn morbidity risk. We used 1998-2003, population-based, Massachusetts birth and death certificates data linked to infant and maternal hospital discharge records from the Massachusetts Pregnancy to Early Life Longitudinal data system. Newborn morbidity risks that were associated with gestational age and selected maternal medical conditions, both independently and as joint exposures, were estimated by calculating adjusted risk ratios. A new measure of newborn morbidity that was based on hospital discharge diagnostic codes, hospitalization duration, and transfer status was created to define newborns with and without life-threatening conditions. Eight selected maternal medical conditions were assessed (hypertensive disorders of pregnancy, diabetes, antepartum hemorrhage, lung disease, infection, cardiac disease, renal disease, and genital herpes) in relation to newborn morbidity. Our final study population included 26,170 infants born late preterm and 377,638 born at term. Late-preterm infants were 7 times more likely to have newborn morbidity than term infants (22% vs 3%). The newborn morbidity rate doubled in infants for each gestational week earlier than 38 weeks. Late-preterm infants who were born to mothers with any of the maternal conditions assessed were at higher risk for newborn morbidity compared with similarly exposed term infants. Late-preterm infants who were exposed to antepartum hemorrhage and hypertensive disorders of pregnancy were especially vulnerable. Late-preterm birth and, to a lesser extent, maternal medical conditions are each independent risk factors for newborn morbidity. Combined, these 2 factors greatly increased the risk for newborn morbidity compared with term infants who were born without exposure to these risks.
    PEDIATRICS 03/2008; 121(2):e223-32. · 4.47 Impact Factor
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    ABSTRACT: Violence is a recognized health risk to the mother, fetus, and infant during pregnancy and first-year postpartum (pregnancy-associated period). Although homicide is a leading cause of injury death among pregnant and postpartum women, the continuum of violence-related physical injuries that women sustain during this period has not been studied systematically. To describe the patterns of physical injuries reported on hospital visits for assault during pregnancy and the postpartum period for a population cohort of Massachusetts women. Using a retrospective cohort design with linked Massachusetts natality and hospital data from 2001 through 2005, 1,468 women (0.9%) who had 1,675 hospital visits (emergency department, observation, and inpatient) for assault were identified. Of these visits, 1,528 visits had at least one physical injury diagnostic code (800-999) from the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9 CM). Applying a modified Barell injury diagnosis matrix that uses the ICD-9 CM injury codes, the first physical injury noted for each visit was classified by body region and nature of injury. Then, the distributions of physical injuries by body region and nature of injury during pregnancy, postpartum, and overall pregnancy-associated periods are described. Also listed are those physical injuries reported in more than 5% of hospital visits for assault during either pregnancy or postpartum period. Of the 1,528 hospital visits for assault with physical injury, the head and neck were the most frequently injured body regions overall (42.2%). The percentage of torso injuries during pregnancy was more than twice that in the postpartum period (21.5% vs. 8.7%). The leading physical injury during both pregnancy (25.4%) and the postpartum (23.1%) period was superficial or contusion to the head and neck. Other common injuries differed by period. Patterns of physical injuries reported on hospital visits for assault for a population cohort provide information that could prove helpful in intervention programs.
    Nursing research 01/2008; 57(3):144-9. · 1.80 Impact Factor
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    ABSTRACT: To assess associations between assisted reproductive technology (ART) and adverse maternal and infant outcomes, with an emphasis on singletons. We linked data from the US ART surveillance system with Massachusetts live birth-infant death records data for resident births in 1997-1998 and compared births conceived with ART (N = 3316) with births not conceived with ART or infertility medications (N = 157,066) on: maternal chronic conditions, pregnancy complications, labor and delivery complications, and perinatal and infant outcomes. Overall, ART was strongly associated with numerous adverse outcomes. The magnitude was reduced for several outcomes when analyses were limited to singletons. After further exclusion of maternal subsets with rare ART births (maternal age <20; education <high school; unmarried, no or public health insurance; no or third trimester prenatal care initiation), and matching ART and non-ART singletons on birth hospital, birth month and year, maternal age, parity, and race/ethnicity, ART remained associated with pre-existing diabetes (Relative Risk [RR] = 2.2 95% confidence interval 1.02-4.9), incompetent cervix (RR = 6.0, [2.3-15.4]), pregnancy-induced hypertension (RR = 1.5, [1.04-2.2]), uterine bleeding (RR = 3.2, [1.5-6.8]), placental abruption (RR = 3.8 [1.6-9.4]), placenta previa (RR = 3.8, [1.6-9.4]), preterm delivery (RR = 2.4, [1.8-3.0]), very preterm delivery (RR = 2.5, [1.2-5.2]), low birth weight (RR = 2.1, [1.5-2.9]), and infant not discharged home (RR = 1.8, [1.2-2.6]). Women who conceive with ART are more likely than women who do not to enter pregnancy with a chronic condition and develop complications during pregnancy and labor and delivery. Additionally, infants born after ART are at increased risk for adverse health outcomes. The mechanisms underlying these associations require further study.
    Maternal and Child Health Journal 11/2007; 11(6):517-25. · 2.24 Impact Factor
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    ABSTRACT: We compared official maternal mortality statistics with those from a special study covering all pregnancy-associated deaths in two European countries (Finland and France) and in two US states (Massachusetts and North Carolina) in 1999-2000 to characterize pregnancy-related deaths that are not included in official statistics. We linked the official ICD-10-based maternal mortality data for 84 deaths with study data on 404 pregnancy-associated deaths. Of the pregnancy-associated deaths, 151 were pregnancy-related. We found 69 pregnancy-related deaths that had not been included as maternal deaths, and two deaths coded as maternal deaths that did not meet our definition for a pregnancy-related death. In total, 58 of these 69 deaths were from medical causes and 11 were from external causes or injuries (10 postpartum depression-related suicides and one accidental drug poisoning). The unreported deaths due to medical causes included 27 direct, 15 indirect, and two direct/indirect pregnancy-related deaths and 14 possibly pregnancy-related deaths. The most common causes of the unreported deaths due to medical causes were intracerebral hemorrhage (7 deaths), peripartum cardiomyopathy (4), pulmonary embolism (4) and pregnancy-induced hypertension (4). The collection of data on pregnancy-related and pregnancy-associated deaths is useful for countries with low maternal mortality figures. The use of various data-collection methods may substantially increase the quality of maternal mortality statistics.
    European Journal of Obstetrics & Gynecology and Reproductive Biology 09/2007; 133(2):179-85. · 1.84 Impact Factor
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    ABSTRACT: Birth and fetal death certificates classify individuals as twins or higher order multiples, but do not identify multiple gestation groups. As a result, multiple gestations are consistently excluded from maternal and child health research studies despite the surge in multiple births since the early 1980s and the health risks associated with them. A standardized methodology for states to identify multiple gestation groups is proposed to allow researchers to account for multiple gestations in analyses, improve the accuracy of the incidence of multiple gestations and further knowledge of the impact of multiple gestations on birth outcomes. Using 3 years of Massachusetts birth and fetal death certificate data from 1998 to 2000 (247,959 births and 1358 fetal deaths), we assigned matching multiple gestation group numbers to records with identical combinations of mother's first name, last name, date of birth, and month of delivery. To validate our methodology, we calculated plurality and compared it to plurality reported on the existing birth and fetal death data. This method correctly identified 10,765 records out of 10,795 validated multiple gestation deliveries (99.8%). Our method identified 71 additional multiple gestation deliveries, which were not identified by the birth and fetal death files. This method resulted in only 4 false positives and 51 false negatives over 3 years. This algorithm provides much needed information on multiple gestation groupings, and as an additional benefit, improves the identification of multiple gestation deliveries. This method has proven easy to use, employs state-level data, and offers numerous new analytic opportunities.
    Maternal and Child Health Journal 06/2006; 10(3):225-8. · 2.24 Impact Factor
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    ABSTRACT: Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality. We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999-2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts. Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France. This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies.
    Obstetrics and Gynecology 11/2005; 106(4):684-92. · 4.80 Impact Factor
  • Revue D Epidemiologie Et De Sante Publique - REV EPIDEMIOL SANTE PUBL. 01/2004; 52:39-40.

Publication Stats

224 Citations
42.06 Total Impact Points


  • 2010–2013
    • University of Massachusetts Lowell
      • • School of Health and Environment
      • • Department of Nursing
      Lowell, Massachusetts, United States
  • 2004–2011
    • Massachusetts Department of Public Health
      Boston, Massachusetts, United States
  • 2008
    • Northeastern University
      • School of Nursing
      Boston, MA, United States