please answer the following questions

Question 1: Select 1 of the 6 journal articles.

a) Discuss how you could utilize and/or adapt its information, concepts, ideas, and/or innovations within your future CNS or NP role (if enrolled in the CNS or NP program) or future professional practice role (if enrolled in the Advanced Certificate in Cultural Competence program).

(Be sure to identify your projected future role and setting and the article you selected).

b) Explain why you selected this one over the other 5 articles.

c) With which course student learning outcome (CSLO) was your selected article most closely aligned? Elaborate in 2-5 sentences.

Question 2:  Spend 15 minutes uninterrupted time to explore the UN Sustainable Development Goals (SDG) website. (Do not use a phone or other small screen device). Select one of the website headings to click on and further explore. Complete the following sentences:

a) I spent 15 minutes on the UN SDG website and the most important discovery I made was __________________.  Elaborate in 2-5 sentences.

b) Exploration of this site fits with developing the following CSLO _______________________. Elaborate in 2-5 sentences.

c) Exploration of this site fits with developing the following CNS or NP core competency __________. (Provide only 1 example and be sure to list corresponding category and number) Elaborate in 2-5 sentences.

Certification Exam Prep – (Synthesized Learning Application)

For your discussion board post:

a) Write the rationale for why an answer is correct or incorrect beneath the response option. Begin your response with “this option is correct because…. Or this option is incorrect because…..”

b) Discuss any feelings you experienced as you worked through the process of answering the question. (See sample list of feelings).

c) Discuss any thoughts you had as you worked through the process of answering the question.

To best provide appropriate nutritional and exercise advice or direct nutritional and exercise promotion services in a culturally congruent way, the transculturally oriented NP or CNS should:

a) try to enter the food and exercise world of the client and understand how they view and use foods and exercise

b) provide internet and written resources written no higher than the grade 6 level in the patient’s preferred language

c) emphasize the balance of hot and cold foods to enhance healing and encourage daily exercise among ethnic minority groups at highest risk for obesity

d) consult with the physician concerning ethnic foods permissible within the prescribed medical diet

Mixed Methods Research
The Impact of Robotic Companion Pets on
Depression and Loneliness for Older Adults
with Dementia During the COVID-19
Pandemic
Donna M. Fogelson, DNP, MSN, MA, APRN, AGCNS-BC, CDP
Carolyn Rutledge, PhD, FNP-BC
Kathie S. Zimbro, PhD, RN
jhn
1
Journal of Holistic Nursing
American Holistic Nurses Association
Volume XX Number X
XXXX 202X 1–13
© The Author(s) 2021
Article reuse guidelines:
sagepub.com/journals-permissions
10.1177/08980101211064605
journals.sagepub.com/home/jhn
Old Dominion University, Virginia Beach Higher Education Center, University Drive
Purpose: Differences in depression and loneliness, during the COVID-19 pandemic, for older adults with
mild to moderate dementia living in residential care after interacting with a robotic companion dog or cat
were explored. Experiences of family members and professional caregivers were also examined.
Design: This study used a mixed research design with pre- and post-questionnaires on depression and
loneliness. Method: Quantitative data exploring the impact of companion pets on depression and loneliness were collected from participants pre-intervention and at 3- and 6-week intervals. Qualitative data
were collected during the 6-week study period, permitting researchers to explore the impact of robotic
companion pets on participants, family members, and professional caregivers. Findings: Results indicated
depression (χ2F(2) = 21.29, p < 0.001) and loneliness (χ2F(2) = 21.11, p < 0.001) improved. Moreover, participants were engaged with their companion pet, providing meaningful, activity and positive experiences. Conclusions: Robotic companion pet therapy, a holistic, nonpharmacologic animal-assisted therapy (AAT), changed the AAT landscape at the study site and provided an alternative option to live pet therapy during COVID-19. Participant interactions with their robotic companion pets enhanced their well-being and quality of life, especially during stringent COVID-19 restrictions and social isolation. Keywords: older adults < group/population; cognitive impairment < specific conditions; animal assisted therapies < healing modalities; alternative/complementary therapies < common themes; COVID-19; loneliness; depression; robotic companion pets Introduction Dementia is not a single disease but is a disease broadly characterized by progressive declines in cognitive, social, and physical functioning (Gustafsson et al., 2015), affecting 6 million Americans (Alzheimer’s Association, 2021) and 50 million individuals worldwide (Wang et al., 2020). Behavioral and psychosocial symptoms include agitation, depression, and loneliness (Hu et al., 2018; Jennings, 1997; Klimova et al., 2019). Symptoms are managed with medications, but effectiveness varies, and side effects persist (Gaugler et al., 2019). Recently, the United States (US) Food and Drug Administration approved Aduhelm™ a new pharmacological therapy for Alzheimer’s disease (Cavazzoni, 2021). However, physicians warn the impact may be limited (Walker, 2021). Moreover, not all patients are eligible, and those that are, may incur substantial out-of-pocket costs exceeding $10,000 annually Author’s Note: Donna M. Fogelson, Old Dominion University, Virginia Beach Higher Education Center, University Drive, Virginia Beach, VA 23456, 7 Still Road, West Hartford, CT 06117-1216, United States. Email: dfoge001@odu.edu 2 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX (Walker, 2021). Animal-assisted therapy (AAT), a holistic, nonpharmacological practice using live animals and robotic pet technology, may be an alternative treatment therapy to enhance quality of life for this vulnerable population (Gustafsson et al., 2015; Klimova et al., 2019; Scales et al., 2018), especially when family visitation is restricted. Further, AAT poses less risk than pharmacological interventions (Hu et al., 2018). In 2016, 41.9% of individuals in the US diagnosed with Alzheimer’s disease or other dementias lived in residential care (Center for Disease Control & Prevention [CDC], 2021). Approximately 47.8% of the individuals residing in nursing homes using longterm care services have dementia (CDC, 2021). Family visits often lessen the effects of loneliness, anxiety, and depression for these residents and are central to their well-being (O’Caoimh et al., 2020). However, deaths among this population increased 16% during the COVID-19 pandemic (Alzheimer’s Association, 2021). Moreover, visitor restrictions and shelter-in-place orders were enforced to protect residents from virus transmission, enhancing social isolation (LeVasseur, 2021). Family gatherings for birthdays, holidays, and other special occasions were canceled. Social activities such as walks, visiting other residents, entertainment, group activities and communal meals were also canceled (Simard & Volicer, 2020). Sequestering residents in their rooms limited social interaction to brief encounters when professional caregivers entered their rooms to deliver medications or perform wellness checks. Unintended consequences of this enhanced social isolation include increased feelings of sadness, depression, loneliness (LeVasseur, 2021), and lack of companionship. AAT using live animals has demonstrated positive effects on quality of life (QOL) and has the potential Figure 1. Joy for All™ Companion Pets, reprinted with permission: © 2018 Ageless Innovation LLC. to reduce social isolation and loneliness for patients with dementia (Klimova et al., 2019). Interaction with live animals promotes sensory stimulation and socialization and enhances well-being (Scales et al., 2018). Physiological effects such as a decrease in blood pressure and an increase in neurochemicals have been realized. Depression in nursing home residents can be reduced when live animals are used during group activities (Majić et al., 2013). Dog-assisted therapy may impact QOL through socialization and communication, providing meaningful activity, and generating positive engagement (Pérez-Sáez et al., 2020). The type of animal used during AAT and the cognitive level of the person can affect interactions with the animal (Thodberg et al., 2016). However, the symptoms of depression had no effect on the type of animal used in the AAT intervention Prior to the COVID-19 pandemic, interaction between residents with cognitive impairments and live animals was encouraged. However, during the pandemic, there was a potential risk, although rare, of animals spreading the virus to humans (CDC, 2020), restricting live animal engagements. Additionally, in some settings, live animals were not permitted due to concerns related to infection control, allergies to pet dander, or fear of animal bites (Hung et al., 2019). Robotic pet technology may provide feasible, effective alternatives to using live animals to manage dementia symptoms (Koh et al., 2021), especially during times when visitation is restricted. Koh et al. (2021) reviewed studies looking at the impact of robotic pets for older adults and people with dementia living in long-term care facilities and in the community setting. In these studies, various tools for measuring outcomes were used depending upon the study variables and included, but not limited to, the Cohen-Mansfield Agitation Inventory, interviews, clinical observation, diary entries, and the UCLA Loneliness Scale (Koh et al., 2021). Banks et al. (2008) found robotic and live dogs in the nursing home improved loneliness scores when residents encountered the live dog and robotic dog compared to the control group (p < 0.05). The researchers used the University of California Los Angeles (UCLA) Loneliness Scale to measure loneliness (Banks et al., 2008). Jennings (1997) looked at the various studies by researchers exploring the potential health promotion benefits of owning a pet. Among the studies reviewed by Jennings (1997), one study mentioned the health benefits of pet ownership in decreasing loneliness and depression in which the researchers noted loneliness was associated with The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. depression. In the study, the researchers used the UCLA Loneliness Scale to measure loneliness. Gustafsson et al. (2015) explored the effects of an interactive robotic cat on social interaction, holding, petting, engagement, and emotional response in older adults with dementia. In this study, the outcomes were measured using the Quality of Life in Late-Stage Dementia scale, the Cohen-Mansfield Agitation Inventory instrument, and qualitative descriptions using an interview guide to collect narratives (Gustafsson et al., 2015). Experiences of family members and caregivers were also explored. Participants demonstrated less agitated behavior and a better QOL over a 12-week period. The authors noted alternative and complementary interventions for individuals with dementia are needed, with the robotic cat a feasible tool to improve dementia care. PARO®, a biofeedback robotic seal used to manage dementia-related symptoms, is another promising example (Petersen et al., 2017). In the Petersen et al. (2017) study, researchers measured the outcomes using various measuring tools including the Rating for Table 1. Descriptive Statistics of Personal Characteristics Personal Characteristics Robotic Animal Cat Dog Gender Male Female Ethnicity White African American Hispanic Asian Native American/Pacific Islander Level of Care ALMC MC LTC Dementia Stage Early Moderate Moderately Severe Level of Education HS/GED Some college Bachelor’s degree Graduate degree n % 8 10 44.4 55.6 2 16 11.1 88.9 18 0 0 0 0 100.0 9 3 6 50.0 16.7 33.3 6 9 3 33.3 50.0 16.7 2 10 1 5 11.1 55.6 05.6 27.8 3 Anxiety in Dementia, Cornell Scale for Depression in Dementia, Global Deterioration Scale, pulse rate, pulse oximetry, galvanic skin response, and medication utilization. Resident use of psychoactive and pain medications was reduced following interaction with the seal. Robotic pets positively impacted mood and affect, social interaction, and overall well-being; however, more research is needed (Koh et al., 2021). Affordability of the robotic pets, ethical issues of attachment, and misrepresentation of the robotic pet as being a live animal are also potential concerns. Robotic pet technology has demonstrated positive effects in AAT sessions without the negative effects of biting, allergic reactions, and infections people may experience with live animals (Klimova et al., 2019), but have not been fully integrated into AAT programs. Moreover, the impact of AAT using robotic pet technology during the COVID-19 pandemic on behavior and psychosocial symptoms for older adults with dementia has not been examined. Purpose This study aimed to explore differences in depression and loneliness for older adults with mild to moderate dementia living in residential care after interacting with a robotic companion dog or cat. Experiences of family members and professional caregivers were also examined. Method The impact of robotic companion pets on dementia symptoms, along with feasibility of integrating companion pets into AAT, specifically when live animals were prohibited, was explored. The intervention took place between October 2020 and December 2020. Quantitative data exploring the impact of companion pets on depression and loneliness were collected from participants pre-intervention and at 3- and 6-week intervals. Qualitative data were collected during the 6-week study period, permitting researchers to explore the impact of robotic companion pets on participants, family members, and professional caregivers. Robotic Companion Pets Joy for All™ Companion Pets (Figure 1) offer an alternative to traditional live animal AAT therapy. These companion pets respond to touch, sound, and motion which allow interaction and engagement 4 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX (Ageless Innovation, 2021). The cat purrs, meows, and moves whereas the dog barks when spoken to, turns its head toward the sound of one’s voice, wags its tail, and when petted, has a heartbeat (Ageless Innovation, 2021). Companion dogs and cats appeal to the memories of the residents having previous pets (Gustafsson et al., 2015). Joy for All™ Companion Pets are interactive and easy-to-care for, making them an attractive alternative to live AAT sessions in nursing homes (Ageless Innovation, 2021). Companion pets are battery operated and have the ability to mute sounds of the dog barking or cat meowing if participants wish a silent interaction. Companion pets have the potential to provide pleasure, comfort, companionship, and improve well-being and QOL for older adults with dementia. The pets are easy to handle and clean. Instituting facility infection control protocols for cleaning the robotic pets helps mitigate possible infection sources and cross-contamination. Setting A 60-bed residential care facility in the northeastern US, caring for older adults with various stages of dementia, was chosen for this study. There were three neighborhoods at the healthcare facility with residents in assisted living memory care (ALMC), memory care (MC), and long-term care (LTC). Professional caregivers and family members were invited to participate. Participants A convenience sample of participants was recruited for this study. English-speaking older adults, residing in the ALMC, MC, or LTC neighborhood, with a dementia stage of 4, 5, or 6 on the Global Deterioration Scale (Reisberg et al., 1982), and expressed an interest to volunteer were invited to participate. Participants with dementia stage 7 or those Table 2. Loneliness Depression Descriptive Statistics: Loneliness and Depression Preintervention 3 Weeks Post Intervention 6 Weeks Post Intervention Mean SD Mean SD Mean SD 23.23 11.31 2.86 2.50 25.46 3.85 2.93 2.85 18.77 2.00 2.71 1.00 who chose not to sign the informed or assent consent were excluded. Participants were informed of the study by their professional caregivers and research flyers. The study sample included 18 participants (2 men and 16 women) completing the preintervention assessments, 14 participants completed the 3-week assessments, and 13 participants completed the 6-week assessments. Participant loss to follow-up included allergic reactions to the companion pet fur (n = 2), the companion pet no longer in the participant’s room (n = 2), and participant demise (n = 1). Participants were predominantly female (88.9%), white (100%), and had a high school education or some college (66.7%) (Table 1). About half resided in the ALMC neighborhood, with 83.3% diagnosed with early or moderate dementia. The companion dog, as opposed to the cat, was selected most often (55.6%) as the pet of choice. The mean age for participants in this study was 89.6 years (SD = 5.7). Intervention The researcher educated professional caregivers on the mechanisms and functional abilities of the robotic companion pets as well as proper handling and cleaning. Additionally, an education storyboard was placed in each neighborhood to use as a reference guide and provided the researcher’s contact information. The intervention was conducted in the privacy of the participant’s room. Each participant received their own companion pet to enhance engagement and interaction, and to mitigate crosscontamination during the COVID-19 pandemic. The researcher explained the companion pet was an alternative to a living animal and not a live pet. Family members and professional caregivers were Table 3. Correlations Between Study Variables Pre-Intervention Personal Attributes Loneliness Depression Age Education Level Dementia Stage 0.017 0.042 −0.111 0.093 −0.416 −0.318 Note: * p < .05 **p < .01 ***p < .001. Dummy variables: education level (1 < 12th grade, 2 = HS/GED, 3 = some college, 4 = bachelors, 5 = graduate); dementia stage (4 = early dementia, 5 = moderate dementia, 6 = moderate/severe dementia). The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. educated not to give participants the impression that the companion pet is a live animal. The researcher demonstrated the functional abilities of the companion pet to each participant and demonstrated how to touch, hold, and stroke the pet. Each participant was given the opportunity to interact and engage with their companion pet for 6-weeks. The companion pet was not removed from the room unless requested by the participant or family. Participants were made aware the companion pet was theirs to keep even if they did not complete the 6-week study. The researcher conducted a 45-min visit with each participant pre-intervention and at 3- and 6-week follow-up visits. These face-to-face visits were not videotaped, or audio recorded. During these visits, participants completed the self-report questionnaires on depression using the Geriatric Depression Scale (GDS)-15 and loneliness using Table 4. Comments from Participants, Family, and Professional Caregivers Participants “I love having her. I put my cat near the window so she could see the snow that is coming” “She’s beautiful. She keeps me company. I don’t have to feed her, and I love it when she purrs” “This is the best dog! I had a dog growing up. Except with this dog, I don’t have to feed him or clean up after him” Family “My mother was matter of fact about the cat at first. Then I called the next week and the cat was purring, and she had to go be with her cat friend” “My mom now goes and visits another resident that has a dog and they have developed a friendship” “She loves the cat, and it gives us something positive to talk about” Professional Caregivers “It was truly amazing how so many residents talked to their pets and cared for them as if they were real animals. Some residents would even take them for a stroll in the hallway” “It was so wonderful seeing residents so engrossed with their animals that they did not remember who I was! I never knew that I would have to take a back seat to a robotic dog and cat” “They love their animals! They take them everywhere. They talk to them and pet them” 5 the UCLA Loneliness Scale (Version 3). The researcher assisted participants by reading the questions to them upon request. Some participants chose to complete the questionnaires in private. Theoretical Framework The Health Promotion Model (HPM) by Nola Pender supports a positive, multidimensional nature of holistic health with the capacity to impact a person’s health behaviors and QOL at all stages of life (Petiprin, 2016). The HPM focuses on behavioral lifestyle changes or modifications that can help improve an individual’s health (Khoshnood et al., 2018). The HPM has been used in previous nursing studies to guide the implementation of interventions to help explain human behavior and behavior change outcomes (Polit & Beck, 2017), and is based on the three constructs of individual characteristic and experiences, behavior-specific cognition and affect, and behavioral outcome (Petiprin, 2016). Individual characteristics and experiences include prior related behavior and personal factors in Figure 2. Participant with Joy for All™ Companion Cat, printed with permission. 6 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX categories of the biological, psychological, and sociocultural (Petiprin, 2016). Behavior-specific cognition and affect comprises several aspects. Perceived benefits of action are the positive outcomes that occur as a result of the health behavior intervention (Petiprin, 2016). Perceived barriers can include the costs, anticipated or real, involved in understanding the health behavior (Petiprin, 2016). Perceived selfefficacy involves the capability of the person to carry out the health promoting behavior (Petiprin, 2016). Activity-related affect is the individual’s positive or negative response to the intervention which can occur before, during, or after the behavior-based intervention (Petiprin, 2016). Interpersonal influences include cognitionconcerning behaviors, attitudes, and beliefs and can be influenced by others including health care team members, family members, and friends. Situational influences can include the setting or environment where the intervention is taking place and can have a direct or indirect effect on the health behavior (Petiprin, 2016). Immediate competing demands can involve environmental concerns the individual may not have control over whereas competing preferences include the behaviors in which individuals have a higher level of control over (Petiprin, 2016). Commitment to the action plan includes the tactic involved in implementing the health promoting behavior (Petiprin, 2016). The health promoting behavior is the positive expected outcome the action or intervention is directed towards (Petiprin, 2016). In this study, individual characteristics, and experiences included prior related behavior (dementia) and personal factors (age, gender, race, education level). The behavior-specific cognition and affect construct included perceived barriers to action (level of care) and situational influences (robotic pet therapy). The specific factors of the pet therapy included the robotic companion pet (cat or dog) which was the independent variable in this study. Under the behavioral outcome construct, the health promoting behavior outcome was aimed at attaining better health outcomes (depression and loneliness) using a holistic approach without the use of medications. Measures The Global Deterioration Scale (GDS) was used to measure the stages of degenerative dementia (Reisberg et al., 1982). The GDS uses a 7-stage rating scale: (a) Stage 1 and Stage 2 - subjectively and objectively normal; (b) Stage 3 – mild cognitive impairment (MCI); (c) Stage 4 – early dementia; (d) Stage 5 – moderate dementia; (e) Stage 6 – moderately severe dementia; and (f) Stage 7 – severe dementia (Reisberg et al., 1982). Each stage describes clinical traits usually exhibited by the individual. The GDS and social demographic data (age, gender, race, education level, and level of care) were collected during the pre-intervention visit. The GDS-15 was used to measure depression (Sheikh & Yesavage, 1986; Yesavage et al., 1983). The Geriatric Depression Scale is a reliable and validated depression screening tool for use with older adults with dementia living in the community, in skilled nursing, or in long-term care facilities (Brown et al., 2015). The GDS-15 has good reliability, with Cronbach’s alpha reported as 0.81, and test-retest strong correlations at 2-weeks (r = 0.84 to 0.85, p < 0.01) (Balsamo et al., 2018). Additionally, the GDS-15 has high sensitivity (92%) and specificity (89%). The scale consists of 15 questions where 10 questions indicate the presence of depression when answered positively; 5 questions indicate depression when answered negatively. Depression level is indicated by the total score on the GDS-15, with a score of 5 or higher suggesting depression. A sample question includes “Have you dropped many of your activities and interests?” Cronbach’s alpha for the GDS-15 in this study was acceptable (0.77). Participants completed the GDS-15 pre-intervention and at 3- and 6-week follow-up visits. The UCLA Loneliness Scale (Version 3) was used to assess loneliness in this study (Russell, 1996). The UCLA Loneliness Scale (Version 3) has been used in studies with the older adult population (Russell, 1996), including older adults with dementia (Sun et al., 2021). This scale has good internal reliability (Cronbach’s alpha 0.89 to 0.94), and test-retest reliability over a one-year period (r = 0.73). This 10-item, self-report tool uses a 4-point Likert scale (1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Always). Loneliness is calculated by summing the scores across the 10 items. The higher the score, the greater the degree of loneliness. A sample item includes “How much of the time do you feel you lack companionship?” Cronbach’s alpha for the UCLA Loneliness Scale (Version 3) in this study was acceptable (0.70). Participants completed the The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. scale pre-intervention and at 3- and 6-week follow-up visits. Ethical Considerations This study was approved by the local Institutional Review Board. The researcher obtained assent or informed consent from participants, their relatives, or legally authorized representatives. Questionnaires were placed in a locked box accessible only to the researcher. Participants’ dementia level was staged, and ethical considerations maintained. Data Analysis Descriptive statistics were used to characterize the study sample. Spearman’s rank correlation coefficients were used to examine relationships between study variables. Friedman’s ANOVA was used to test differences between measurement periods. Post hoc tests were completed using pairwise Wilcoxon signed-rank tests. Statistical significance for post hoc tests were evaluated against a Bonferroni-adjustment alpha level of 0.017 (0.05/3) since multiple pairwise comparisons were performed on the same dataset. SPSS Statistics for Windows version 26, SPSS Inc., Chicago, Ill., US, was used to analyze study data. Qualitative data were used to explore participants, family members, and professional caregivers’ perceptions of the impact, use, and qualities of robotic companion pets in their environment. Results Quantitative Analyses Descriptive statistics for loneliness and depression are presented in Table 2. Relationships between participant characteristics, loneliness and depression were not statistically significant (Table 3). Friedman’s ANOVA showed a significant improvement in loneliness (χ2F(2) = 21.11, p < 0.001) across the measurement periods. Post-hoc tests revealed loneliness was significantly reduced between pre-intervention and 6-weeks postintervention (Z = -3.06, p = 0.002) and between 3-weeks post-intervention and 6-weeks postintervention (Z = -3.07, p = 0.002). Significant changes in loneliness between the pre-intervention and 3 weeks post-intervention (Z = -2.37, p = 0.018) measurement periods were not realized. 7 Friedman’s ANOVA showed a significant improvement in depression (χ2F(2) = 21.29, p < 0.001) across the measurement periods. Post-hoc tests revealed depression was significantly reduced between pre-intervention and 3-weeks postintervention (Z = -3.19, p = 0.001), between preintervention and 6-weeks post-intervention (Z = -3.06, p = 0.002), and between 3- weeks and 6-weeks post-intervention (Z = -3.07, p = 0.002) measurement periods. Qualitative Data Study site leadership did not permit focus groups with participants, professional caregivers, and family members due to COVID-19 restrictions. Instead, the researcher conducted individual interviews to inquire about their perceptions of program impact on participant well-being. Perceptions provided by participants, family, and professional caregivers are presented in Table 4. Overall perceptions related to robotic companion pet experiences were very positive, with pets providing companionship for participants and improving communication. For example, one participant commented “I love having her. I put my cat near the window so she could see the snow that is coming” (Figure 2). Professional caregivers and family members also commented on the positive impact of robotic companion pets on participants’ well-being. One family member commented “She loves the cat, and it gives us something positive to talk about” providing opportunities for meaningful conversation, especially during the pandemic when family visitation was restricted. A professional caregiver mused “It was so wonderful seeing residents so engrossed with their animals that they did not remember who I was! I never knew that I would have to take a back seat to a robotic dog and cat.” Participants, professional caregivers, and family members indicated the program should be continued and expanded. Discussion Findings for this study were not consistent with the literature (Banks & Banks, 2002; Klimova et al., 2019; Scales et al., 2018) at the 3-week interval as participant interaction with the companion pet did not have a positive impact on loneliness. It is important to note, this study was conducted during the COVID-19 pandemic when visitor restrictions and 8 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX shelter-in-place orders were enforced. Additionally, the live therapy dog was restricted from entering the facility due to concerns of virus transfer to residents. Moreover, participants were notified by professional caregivers during the 3-week data collection period that family visitation would not be permitted during the upcoming Thanksgiving holiday due to a rise in COVID-19 positivity rates in the community. Participants expressed dissatisfaction with the decision and indicated they would be lonely during the holiday. It is unclear to what extent this news negatively impacted study results related to loneliness at this time interval. The researcher spent at least an hour with each participant, at their request, to discuss the decision to restrict family visitation during the holiday. Study results 6-weeks following program implementation were in concordance with the literature (Banks & Banks, 2002; Gustafsson et al., 2015; Klimova et al., 2019; Pérez-Sáez et al., 2020; Scales et al., 2018; Thodberg et al., 2016) in that reported depression and loneliness scores were significantly lower following interaction with the companion pet. Participants, family members, and professional caregivers were very positive about interactions with the companion pets. Family members noted new opportunities to engage their loved ones in meaningful conversations, which they found very satisfying. In this study, infection control barriers to using robotic technology in AAT were consistent with those reported by Hung et al. (2019). Special infection control practices for cleaning the companion pets were required by the study facility, particularly given the COVID-19 pandemic environment. Professional caregivers were educated about infection control cleaning procedures prior to participants receiving their companion pets. Overall, companion pets required less care than live animals, were safe to use, particularly for people who may be allergic to pet dander or fear the animal may bite (Hung et al., 2019), and decreased the risk of zoonotic pathogens transmitted from animals to humans (CDC, 2015). Furthermore, with infection control practices in place, providing participants with their own robotic companion pet mitigated cross-contamination risk. Cost barriers were consistent with those reported in the literature (Hung et al., 2019). Funding to purchase individual robotic companion pets was critical to program success. Intangible results of enhanced participant satisfaction, increased well-being, and QOL were considered essential benefits when the cost-benefit analysis to secure funding was conducted. Additionally, AAT has the potential to be a cost-effective intervention by decreasing the use of psychotropic medications and improving the QOL in residents with dementia (Briones et al., 2021). In this study, resources to mitigate the cost of companion pets were provided by the study site and vendor for the companion pets. Funding may be available from the National Institute on Aging (NIA) for research using nonpharmacological intervention development in the areas of dementia care, caregiver research, and prevention (NIA, 2021). Methodological Considerations Limitations for this study included the use of a small convenience sample at one residential care facility. This study was conducted during the COVID-19 pandemic, significantly restricting participant interactions with their family, which may have negatively impacted changes in loneliness. Repeating the study when family visitation restrictions are lifted, may produce different results. The results are not generalizable but may be transferable to similar residential care environments (Gustafsson et al., 2015). Implications for Advancing Knowledge, Practice and Research There is a growing need for alternative and complementary nonpharmacological interventions to manage health outcomes for the increasing number of residents with dementia (Gustafsson et al., 2015). AAT programs, using robotic companion pets, is an innovative, holistic, nonpharmacological technological intervention that can be applied in multiple healthcare and community settings. AAT can be part of the treatment process with the goal to enhance social, physical, and cognitive functions thus improving a person’s well-being (Klimova et al., 2019) and all care providers can participate. Physical activity is improved by petting the animal, and communication skills are enhanced when bonding with the animal (Gustafsson et al., 2015; Klimova et al., 2019). The body releases endorphins and other hormones when interacting with the animal through hugging or petting (Klimova et al., 2019). Facilitating interprofessional collaboration and team building, implementation of an AAT program engages the The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. interprofessional team in promoting positive outcomes between staff and residents at the facility (Mills et al., 2019). The findings from the study have the potential to impact practice and patient care to improve care and health outcomes for older adults with dementia. This study was conducted during a pandemic where visitor restrictions and shelter-in-place orders were in effect. Additionally, the live pet therapy dog at the facility was restricted from entering the facility at the onset of the pandemic. Implementing this type of holistic program coincides with improving the health of older adults with dementia and advancing nurse practice. The American of Colleges of Nursing (AACN) describes the call for action to focus on health promotion and disease prevention among vulnerable populations and to refine assessment skills in specialized populations (AACN, 2006). Additionally, on a national level, this type of holistic, nonpharmacological program supports the Healthy People 2030 goal to improve the health and quality of life for individuals living with dementia (CDC, 2020). This study adds to the limited body of research in the US currently available on the use of robotic companion pets in cognitively impaired older adults. In this study, AAT was explored in the cognitively impaired older adult with dementia looking at the potential to decrease depression and loneliness using the companion pets. Taking into consideration clinical scholarship and evidence-based practice, more research is needed, and the scope of AAT needs to be expanded in order to explore AAT and psychotropic medication use. In the study conducted by Briones et al. (2021), the researchers explored enhancing the QOL for dementia patients with the use of AAT, specifically, using a dog, to reduce dementia related symptoms such as agitation, depression, insomnia, and the use of psychotropic medications. The researchers concluded more research needed to be done to evaluate AAT and the use of psychotropic medications (Briones et al., 2021). In the study by Lu et al. (2021), the researchers reviewed literature on the effectiveness of using robot care for people with dementia measuring agitation, depression, and QOL. When the people with dementia were exposed and engaged with pet-type robotics, the researchers found these type of pets stimulate interaction and had a positive effect on depression in people with dementia (Lu et al., 2021). The researchers suggested additional studies 9 be conducted in the field of pet-type robotics for use in therapy programs. There are resources available to fund an AAT program. The vendor of the robotic animals is a potential source of funding as well as the facility or hospital planning to conduct the research. Additionally, the NIA has funding opportunities available for research using nonpharmacological intervention development in the areas of dementia care, caregiver research, and prevention (NIA, 2021). Providing a nonpharmacological intervention, such as an AAT program, in the facility, hospital, or community has the potential to improve health care outcomes in the older adult population. There are many opportunities to improve the health outcomes of older adults with dementia and improve their QOL. This research identified a nonpharmacological intervention that can be implemented to decrease depression and loneliness in older adults. As holistic nursing professionals, facilitating interprofessional collaboration through the implementation of this alternative AAT program has the potential to engage professional caregivers in promoting positive outcomes between the caregivers and the residents at the facility. As clinical leaders, working with professional caregivers to allocate the time for caregiver implementation of this program is essential in fostering leadership and team building. Systems leadership for quality improvement has the potential to create a system-wide change in holistic nursing practice delivery as well as improving health outcomes (AACN, 2006). Using an interprofessional team building approach to engage unit champions with implementing the program has the potential to create opportunities for other health care professionals to engage and participate with the residents in this type of program (Mills et al., 2019). Additionally, having unit champions model program implications can encourage and motivate staff members to become involved in executing the program within their unit or neighborhood to improve patient outcomes. Facilitating team building and collaboration contributes to improved patient outcomes by providing individualized, holistic, person-centered care for the older adult population (AACN, 2006). From a business practice, securing the funds needed to purchase the robotic companion pets for the AAT program is essential to the success of the program. With current COVID-19 infection control practices in place, the ability for each resident or 10 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX patient to have their own robotic companion pet helps to mitigate the risk of cross-contamination between residents or patients is essential. When using a cost-benefit analysis to secure the needed funds, consideration of the intangible results of improved patient satisfaction and QOL should be considered as essential benefits. Additionally, AAT has the potential to be a cost-effective intervention by decreasing the use of psychotropic medications and improve the QOL in dementia patients (Briones et al., 2021). Using the holistic, nonpharmacological technology of robotic companion pets as an AAT intervention to improve health outcomes, supports nursing practice to improve and transform healthcare in this vulnerable population (AACN, 2006). Robotic companion pets in AAT programs have implications for policy and the potential to change the landscape of pet therapy especially for those with allergies to pet dander, potential disease transmission, fear of animal bites, and where live animals are not permitted into facilities. With proper health and infection control policies in place at facilities, the use of robotic companion pets in AAT programs has the potential to decrease the risk of zoonotic pathogens transmitted from animals to humans (CDC, 2015). The use of robotic companion pets in AAT programs is a technology that can be applied in multiple healthcare and community settings to improve health care outcomes in older adults with dementia supporting holistic nursing practice as well as patient care technology for the improvement and transformation of health care (AACN, 2006). In a study by Moyle et al. (2012), family members of loved ones with dementia felt the robotic animal improved their loved one’s well-being. Anecdotal comments provided by participants, families, and professional caregivers supported this notion. Kelly et al. (2021) conducted a study using the robotic PARO® seal in an acute care setting for hospitalized patients with dementia. The study was conducted with patients in three units of the hospital which included orthopedics, progressive cardiac care, and medical-surgical with study results showing potential for positive social and affective interactions (Kelly et al., 2021). Neal et al. (2020) reported the use of robotic animals in adults with dementia increased positive behaviors and an improved QOL. Robotic animal technology has the potential to decrease depression and loneliness in older adults with varying cognitive impairments. In this research, participants were engaged and stimulated by the interaction with their companion pet, providing a meaningful activity and generating positive engagement. Conclusions Robotic companion pet technology is holistic and innovative, and this technology changed the AAT landscape at the study facility, especially when live animals were restricted. Companion pets improved depression and loneliness without risks associated with pharmacological interventions (Hu et al., 2018). Participants were engaged with their companion pet, providing meaningful activity and positive experiences, especially when COVID-19 restrictions were at its worse, with participants sequestered, and family visitation restricted. More importantly, conversations between participants, family, and professional caregivers enhanced the therapeutic milieu. Acknowledgments Funding for the companion pets for this research was provided by Duncaster Foundation and Ageless Innovation LLC. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Duncaster Foundation and Ageless Innovation LLC. ORCID iDs Donna M. Fogelson https://orcid.org/0000-0002-4779-849X Kathie S. Zimbro https://orcid.org/0000-0001-8841-2664 References Ageless Innovation (2021). Joy for All™ companion pets guide for family caregivers. https://agelessinnovation.com/ wp-content/uploads/2020/05/CareGuide_ENGLISH_Master1.pdf. The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. Alzheimer’s Association (2021). Facts and figures. https:// www.alz.org/media/documents/alzheimers-facts-and-figuresinfographic.pdf. American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from https://www.aacnnursing.org/DNP/ DNP-Essentials. Balsamo, M., Cataldi, F., Carlucci, Padulo, C., & Fairfield, B. (2018). 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The Wall Street Journal, https://www.wsj.com/articles/first-alzheimersdrug-to-slow-disease-is-approved-by-fda-11623078912. Wang, H., Li, T., Barbarino, Gauthier, S., Brodaty, H., Molinuevo, J. L., Xie, H., Sun, Y., Yu, E., Tang, Y., Weidner, W., & Yu, X. (2020). Dementia care during COVID-19. Lancet (London, England), 395(10231), 11901191. https://doi.org/10.1016/S0140-6736(20)30755-8 Yesavage, J. A., Brink, T. L., Rose, T. L., & Lum, O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. https://doi.org/10. 1016/0022-3956(82)90033-4 Author Biographies Dr. Donna M. Fogelson, is a board-certified Adult-Gerontology Clinical Nurse Specialist and Educator. She is a Nursing Adjunct Clinical Faculty member at the University of Connecticut and University of Saint Joseph. Dr. Fogelson was honored as the 2021 recipient of the DNP Scholarship Award by the Old Dominion University School of Nursing. Research interests include community and population health, complementary, alternative, and integrative health. Dr. Carolyn Rutledge, is a Professor and Associate Chair of the Graduate program in Nursing, and the current Director of the DNP program at Old Dominion University. Dr. Rutledge practices in the clinical setting as a Family Nurse Practitioner at Eastern Virginia Medical School. Dr. Kathie S. Zimbro, s the Nurse Executive for Research and Lead Nurse Scientist for Sentara Healthcare. She conducts research and disseminates findings that shape the future of health care. Research interests include population health, palliative care, and predictive modeling. She has 33 manuscripts published in referred journals and over $1.6 million in extramural The Impact of Robotic Companion Pets on Depression and Loneliness / Fogelson et al. funding. Dr. Zimbro is a member of the Editorial Board of the Journal of Nursing Care Quality. Dr. Zimbro was honored as the 2017 recipient of the Clinical Researcher Award by the 13 Southern Nursing Research Society Governing Board. In 2021, Dr. Zimbro was awarded the Daisy Lifetime Achievement Award by the Daisy Foundation™. Ecology of Food and Nutrition ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/gefn20 The influence of cultural food security on cultural identity and well-being: a qualitative comparison between second-generation American and international students in the United States Kathrine E. Wright, Julie E. Lucero, Jenanne K. Ferguson, Michelle L. Granner, Paul G. Devereux, Jennifer L. Pearson & Eric Crosbie To cite this article: Kathrine E. Wright, Julie E. Lucero, Jenanne K. Ferguson, Michelle L. Granner, Paul G. Devereux, Jennifer L. Pearson & Eric Crosbie (2021) The influence of cultural food security on cultural identity and well-being: a qualitative comparison between second-generation American and international students in the United States, Ecology of Food and Nutrition, 60:6, 636-662, DOI: 10.1080/03670244.2021.1875455 To link to this article: https://doi.org/10.1080/03670244.2021.1875455 Published online: 25 Feb 2021. Submit your article to this journal Article views: 729 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=gefn20 ECOLOGY OF FOOD AND NUTRITION 2021, VOL. 60, NO. 6, 636–662 https://doi.org/10.1080/03670244.2021.1875455 ARTICLE The influence of cultural food security on cultural identity and well-being: a qualitative comparison between secondgeneration American and international students in the United States Kathrine E. Wright a, Julie E. Lucero a,b, Jenanne K. Fergusonc, Michelle L. Grannera, Paul G. Devereuxa, Jennifer L. Pearsona,d, and Eric Crosbiea,e a School of Community Health Sciences, University of Nevada Reno, Reno, Nevada, USA; bLatino Research Center, College of Liberal Arts, University of Nevada Reno, Reno, Nevada, USA; cCollege of Arts and Sciences MacEwan University Edmonton, Alberta; dBloomberg School of Public Health Johns Hopkins University Baltimore, Maryland; eOzmen Institute for Global Studies University of Nevada Reno Reno, Nevada ABSTRACT KEYWORDS The purpose of this study was to explore the impact of cultural food insecurity on identity and well-being in second-generation American and international university students. Thirty-one semi-structured interviews were conducted from January– April 2020. Audio transcripts were analyzed using continuous and abductive thematic analysis. Students indicated that cul­ tural foodways enhanced their well-being by facilitating their cultural/ethnic identity maintenance, connection, and expres­ sion. Conversely, cultural food insecurity diminished student well-being due to reduced cultural anchors, highlighting the importance of cultural food in this population. Universities that reduce cultural foodways barriers may mitigate cultural food insecurity for second-generation American and interna­ tional university students. (100/100) Food Security; culture; identity; well-being; student Introduction Food is not only a means used to alleviate hunger, but it also shapes one’s cultural and ethnic identity through foodways or traditional meal practices and habits such as cultural food preparation, sharing, and consumption (PSC; Warde 1994). Foodways are physical and symbolic acts that help immigrants1 preserve their cultural identities and subsist change during migration (D’Sylva and Beagan 2011). Because of the powerful connection between food and identity, immigrants often have a vehement desire to preserve and maintain their cultural or ethnic identity through traditional foodways when relocating to a culturally different environment (Beoku-Betts 1995). Carrying out tradi­ tional meal practices, whether it be within or between cultures, often evoke positive, nostalgic memories of home, family, and belonging (Locher et al. CONTACT Kathrine E. Wright kathrine.e.wright@gmail.com of Nevada Reno 1664 N. Virginia Street, Reno Nevada, 89557. © 2021 Taylor & Francis Group, LLC School of Community Health Sciences University ECOLOGY OF FOOD AND NUTRITION 637 2005; Osella and Osella 2008), which can be a positive mental, emotional, or physical experience (Boutaud, Becuţ, and Marinescu 2016; Santos, McClelland, and Handley 2011; Vallianatos and Raine 2008). Creating food memories is essential as travel to one’s homeland may not be feasible. Therefore, cultural food consumption keeps the memories of the transnational relationships alive, allows the individual to have a sense of connectedness to their culture, and sustains a familiar sense of self (Abarca and Colby 2016). Thus, with the increase of U.S. immigrants, a rationale for qualitative research exists and warrants examining immigrant food experiences and exploring the mechanisms and pathways that connect foodways, identity, and well-being. When immigrants experience cultural food insecurity, traditional foodways may be diminished or eliminated. Power (2008) defined cultural food inse­ curity as having unreliable access to traditional/country food through tradi­ tional harvesting practices. Translating “harvesting practices” into other cultures include the ability to attain cultural foods. To further extend upon Power’s definition, cultural food security exists when there is the availability, access, utilization, and stability of cultural foods (Alonso, Cockx, and Swinnen 2018). The inability to carry out traditional foodways when cultural food security is not present may lead to feelings of cultural identity degradation and ethnic isolation (Vallianatos and Raine 2008). Previous research has shed light on how social identity influences health and well-being (Haslam et al. 2018). Since food is often used to maintain identity and connections to home for immigrants, consuming cultural foods that are familiar is associated with feelings of pleasure, comfort, and well-being (Coveney and Bunton 2003). Unfortunately, foodways can be strained when moving to a culturally dissimilar environment causing acculturative stress (i.e., stressors associated with cultural transitions; Berry 2006; Berry et al. 2006) and culture shock (i.e., the uncertainty and anxiety that individuals feel from moving to a culturally unfamiliar environment; Oberg 1960). Culture shock and accultura­ tive stress are often due to significant environmental differences such as food, language, and cultural norms (Angel, Buckley, and Sakamoto 2001; Brown and Holloway 2008a, 2008b; Chang 2009; Liebkind, Jasinskaja-Lahti, and Solheim 2004; Sodowsky & Wai Ming Lai, 1997). Both acculturative stress and culture shock can lead to identity conflict and negatively impact well-being (Kim 2001; Lum & Le Vayer, 2016; Ward, Bochner, and Furnham 2001). Scholars have seen similar negative well-being impacts due to culture shock and acculturative stress in immigrant and international (INT) students (Angel, Buckley, and Sakamoto 2001; Brown 2008, 2009a, 2009b; Brown and Holloway 2008a, 2008b; Chang 2009; Liebkind, Jasinskaja-Lahti, and Solheim 2004; Sodowsky and Wai Ming 1997; Ward, Bochner, and Furnham 2001; Warde 1994), as immigrant and international (INT) students can experience a temporary stay in a culturally unfamiliar place for academic study (i.e., academic sojourn). Therefore, immigrant and international students must 638 K. E. WRIGHT ET AL. maintain their cultural and ethnic identity as it has positive effects on wellbeing and health-related quality of life outcomes (Gray-Little and Hafdahl 2000; Ryff, Keyes, and Hughes 2003; Tsai, Ying, and Lee 2001; Umaña-Taylor, Diversi, and Fine 2002; Utsey et al. 2002). Most research investigating the effects of identity, acculturation, and wellbeing in international and immigrant students focused on one racial or ethnic group and was often only assessed quantitatively (Jung, Hecht, and Wadsworth 2007; Lee, Yoon, and Liu-Tom 2006; Schwartz et al. 2013). Study results from Schwartz et al. (2013) and Jung, Hecht, and Wadsworth (2007) indicated that strong attachment to one’s cultural identity was asso­ ciated with improved well-being in immigrant students. An additional study found that cultural assimilation played a vital role in the psychological wellbeing of Asian international students (Lee, Yoon, and Liu-Tom 2006). Research findings also indicated the importance of identity maintenance and welfare for immigrants (Peñaloza 1994; Rabikowska 2010; Weller and Turkon 2015; Williams-Forson 2014). Another population that is frequently overlooked in this area of research is second-generation American (SGA) students. We contend that SGA stu­ dents are also academic sojourners as they can move to culturally unfamiliar environments, producing culture shock, and acculturative stress (Wright et al. 2021). Thus, when SGA and international students feel cultural stress, strain, and shock, determining ways to preserve identity could improve well-being outcomes during the collegial transition (Outten et al. 2008; Ruiz 1990). It is argued that INT students should be considered temporary immigrants in the United States as their international sojourn (i.e., an international temporary stay) can last numerous years and many INT students become permanent U.S. residents after graduation, thus transition into first-generation U.S. Americans (Hazen and Alberts 2006). Thus, it is plausible that INT students have similar connections with cultural foods and foodways, as described ear­ lier in immigrants. Thereby, it is necessary to understand how the momentous environmental changes that occur with collegial transition affect INT and SGA students’ well-being. Prior scholars have argued that the term “immigrants” should encompass both first-generation and second-generation immigrants (Portes and Rumbaut 2006). Portes et al. (2006) argue that even though second-generation Americans (SGAs) are born in the United States (U.S), they share similar experiences as their first-generation counterparts as SGAs grow up in the home of immigrants who express culture and heritage from their home countries (Portes and Rumbaut 2006). Additionally, both populations have to balance their cultural identity with “mainstream” American culture (Schwartz et al. 2010). While first-generation and second-generation immi­ grants share these similarities, first-generation immigrants differ regarding assimilation and acculturation, such as language barriers, academic struggles, ECOLOGY OF FOOD AND NUTRITION 639 and the immersion into American culture (Misra and Castillo 2004; Misra, Crist, and Burant 2003; Ramanaidu 1991). While SGA and INT students share similar characteristics, we assert that these two groups’ experiences are differ­ ent enough to warrant a separation in research. There is minimal research investigating the relationships between cultural food security, identity, foodways, and well-being in INT and SGA populations. Thus, this research seeks to build upon our previous research examining the relationship between cultural food, identity, and well-being in secondgeneration American (SGA) college students using the food experience con­ ceptual framework (see Figure 1 below). We found that cultural food security allowed SGA students to prepare, share, and consume (PSC) their cultural foods [pathway 1A, see Figure 1], which played a crucial role in SGA identity formation and maintenance. The SGA students’ identity reinforced the prac­ ticed foodways [pathways 2A and 2B]. The SGA student’s well-being was enhanced through traditional meal practices [pathway 2 C]. Lastly, traditional foodways brought about happiness, safety, and warmth as meal practices produced memories of their family and cultural ties [pathways 2D and 3 C]. The purpose of this exploratory study is to compare the cultural food experience and its influence on the identity between SGA college students who self-identify as a cultural or ethnic minority and INT students. While these two populations share some common characteristics (e.g., having cul­ tural foods, foodways, and non-dominant cultural identity), their life experi­ ences are quite different (e.g., the ability to connect with others that share similar identities, travel experience, and country of origin). We propose these differences influence identity, well-being, and access to traditional cultural foods. The differences between these populations may affect the relationship between cultural foods, identity, and well-being. Understanding these differ­ ences can help universities provide students with the necessary support to alleviate culture shock and acculturative stress. Methods and materials Context Data collected by the American Community Survey in 2019 indicated that Reno, Nevada had a population of roughly 256,000 residents (US Census Bureau 2019). Racial and ethnicity data revealed that 61.1% of Reno’s residents identified as non-Hispanic/Latino White, 24.7% identified as Hispanic, 6.5% identified as Asian, 4.8% identified as two or more races/ethnicities, 2.7% identified as Black alone, 1.1% identified as Native American or Alaskan Native, 0.8% identified as Native Hawaiian or other Pacific Islander, and 0.2% identified as “other” (US Census Bureau 2019). Additionally, 16.0% of Reno's population was foreign-born, in which 56% were born in Latin 1A Foodways Food Preparation Food Sharing Food Consumption 2B 2A Well-being Physical Mental Emotional 3C Memories 3B Food Identity Figure 1. Conceptual framework explaining how cultural food security influences identity and well-being in international and second-generation American students. Cultural Food Security Access Availability Quality Identity National Ethnic Cultural Religious/Spiritual Gender Regional Language Personal Familial 640 K. E. WRIGHT ET AL. ECOLOGY OF FOOD AND NUTRITION 641 America, 32% in Asia, 7% in Europe, 2% in Asia, 2% in Africa, and 1% in Oceania (Census Reporter 2019). Participants Participants in this study included 31 participants; 16 second-generation American undergraduate (n = 13) or graduate (n = 3) students, and 15 undergraduate (n = 1) or graduate (n = 14) international students at the University of Nevada, Reno (an urban, Western university). The sample size was determined by examining similar studies with first and second-generation college student participants (Brady and Stevens 2019; Eaton 2006; Morales 2012; Muñoz 2012; Schackmuth 2012; Skulley 2004), as well as studies with international college student participants (Constantine et al. 2005a, 2005b; Moores and Popadiuk 2011; Tummala-Narra and Claudius 2013; Yuan 2011). Participant demographics are shown in Tables 1 and Tables 2. Eligibility and recruitment The purposive sample included SGA and INT students who were 18 years of age or older, believed that food was a critical component of their cultural/ ethnic identity, and were students at the university. Additionally, SGA stu­ dents self-identified as a cultural or ethnic minority were included. Participants were considered SGA if they were born in the U.S., and at least one parent was born and raised in a country outside the United States (Peguero 2008). Participants were excluded if they did not meet these criteria. The first author posted flyers around campus with study details and sent out e-mails to different faculty, departments, and student clubs to recruit student participants. Both the flyers and e-mails included a link to the screener survey to determine participant eligibility and collect some demographic details. The screener included information about students’ education level (undergraduate or graduate), how they paid for their tuition, weekly hours worked, selfdescription of their cultural or ethnic identities, and country of origin. Some demographic information was omitted to maintain the students’ anonymity due to small population group sizes on campus. The students’ food security level was calculated using the USDA’s six-item food security module (Economic Research Service & United States Department of Agriculture, 2012). The responses of often, sometimes, yes, almost every month, and some months but not every month were coded as affirmative responses, and one point was added to their food security score. Total food insecurity scores 0–1 were interpreted as high food security, 2–4 as low food security, and 5–6 as very low food security (Economic Research Service, & United States Department of Agrictulture 2012). The assessment of cultural food insecurity was indicated by yes or no response to the questions, 642 K. E. WRIGHT ET AL. “Since starting college, have you experienced the inability to purchase the foods that you used to eat at home?” and “Did the inability to purchase your traditional food happen within the last three years?” The research team emailed eligible students and provided additional study details along with a link to set up an interview with the first author. Tables 1 and Tables 2 highlight the information collected in the screener survey. Interview procedures The research team utilized an exploratory qualitative methodology. Information about INT and SGA students’ food experience was collected through semi-structured interviews conducted from January 2020– April 2020. The interview questions sought to elicit information about how cultural foods play a role in one’s identity, to understand further how one’s well-being is influenced by the presence or lack of cultural cuisines. Interview questions focused on defining identity, the role of food in identity, food memories, cultural food significance, cultural food insecurity experiences and emotions, and the influence that foodways have on identity and wellbeing (Table 3). Thirty-one out of 58 eligible students agreed to be interviewed for this study under an approved protocol by the the University of Nevada, Reno's Institutional Review Board. While 58 participants were eligible for participation, 21 students did not respond to six follow-up e-mails, and six participants opted out of interview participation. The first-author collected written consent before the interview commenced. Twenty-four of the interviews occurred face-to-face; however, because of the COVID-19 pandemic, seven interviews occurred over Google Hangouts to protect the students’ and interviewer’s health. E-signatures were obtained for written consent for these seven participants. The audiorecorded interviews averaged 70 minutes. All study data were stored anon­ ymously, with all identifiable information removed. To further protect the students’ anonymity, the participants created pseudonyms during the consent process before the interview recording. Once the interview commenced, only the students’ pseudonyms were used to enhance identity protection further. Qualitative analysis The audio was transcribed verbatim, and transcripts were then analyzed using continuous and abductive thematic analysis procedures to uncover themes and subthemes. The analysis was deductive (a priori themes from the con­ ceptual framework) and inductive (arising from participants’ views). The transcripts were read and re-read to promote familiarity with the transcripts’ content. Memos were written down to pinpoint patterns in the data and create emergent codes. The first author first coded four transcripts ECOLOGY OF FOOD AND NUTRITION 643 Table 1 Participant Identities. Pseudonym Second-Generation Alice Jasmine Sarah Jennifer Cloud Theresa Joanna Mary Chelsey Cyrus Sam Fraction Angel Aaron Jessie Daniel International Julia Juan Pablo Jack Elizabeth Elnoor Anouk Flora Fernanda Sophia Luna Alpha Monica Lisa Joe Alex Gender Self-Identified Cultural or Ethnic Identity Country of Origin Female Female Female Female Male Female Female Female Female Male Female Male Male Male Female Male Mexican Filipino and Chinese Chinese, Korean, Laotian, and Mexican Latina Thai and Taiwanese Hispanic Hispanic/Latina Filipino Filipino Middle Eastern Eritrean, African American Hispanic/Latino Latino and Hispanic Asian American Chinese Armenian United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States Female Male Male Female Male Female Female Female Female Female Male Female Female Male Female Hispanic and Latinx Latin Spanish, European Iranian Azerbaijani Spanish Italian White Hispanic Asian Latin and White Yoruba and African Chinese African Vietnamese/Asian Romanian Mexico Ecuador Spain Iran Azerbaijan Spain Italy Brazil China Brazil Nigeria China Kenya Vietnam Romania using a priori codes based on the conceptual framework. Emergent codes were identified, discussed with the second author, and then applied to the data. Once all codes were decided upon, and a consensus among the research team occurred, a codebook was developed to define the codes, which were then applied to all transcripts. Once patterns in the data appeared, the first author examined emergent and a priori codes to construct the final codes that were named, defined, and discussed with the second author. Once an agreement was reached amongst the research team, a codebook was developed. Next, all transcripts were coded using the final code set. These codes were then queried and re-analyzed and then pooled into themes and subthemes. The research team reexamined the coding for confirmation of coding reliability. Results Participant demographics Participants included both undergraduate (n = 14) and graduate (n = 17) students, of which 11 participants were male, and 20 were female. The top 644 K. E. WRIGHT ET AL. Table 2. Participant and Non-Participant Demographics. Second – Generation n = 16 (%) College Level Undergraduate Graduate Gender+ Male Female Tuition Payment* Job(s) Scholarship or Fellowship Loans or Grants Graduate Assistantship Parents Weekly Hours Worked 0–20 21–40 Cultural Food Insecurity (in the last three years) Yes No Food Security Score High (0–1) Low (2–4) Very Low (5–6) International n = 15 (%) Non – Participants% n = 27 (%) 13 3 (81.25) (18.75) 1 14 (6.7) (93.3) 21 6 (77.8) (22.2) 6 10 (37.5) (62.5) 5 10 (33.3) (66.7) - 7 10 12 2 5 (19.4) (27.8) (33.3) (5.6) (13.9) 3 8 0 13 2 (11.5) (30.8) (0) (50) (7.7) 7 19 14 6 11 (12.3) (33.3) (24.6) (10.5) (19.3) 11 5 (68.7) (31.3) 12 3 (80) (20) 22 5 (81.5) (18.5) 9 7 (56.3) (43.7) 15 0 (100) (0) 14 13 (51.9) (48.1) 7 8 1 (43.7) (50) (6.3) 10 4 1 (66.7) (26.6) (6.7) 11 7 9 (40.7) (26) (33.3) % Non-participants include those who did not respond to follow up e-mails or declined an interview + Gender information was collected during the interviews. “Male” and “female” were the only gender responses participants gave. Gender information was not collected for non-participants. * Participants were able to select more than one option three forms of tuition payment for SGA students were employment, scholar­ ships or fellowships, and loans or grants. This differed from the top three forms of tuition payment for INT students, which included employment, scholarships or fellowships, and graduate assistantships. Most INT and SGA students worked between 0–20 hours per week. All 15 INT (100%) students indicated that they experienced cultural food security in the last three years compared to 56.3% of the SGA students. More than 60% of SGA students had low or very low food security scores, which was nearly 30% points higher than INT students (33.3%). These stark differences indicate divergent food inse­ curity experiences between SGA and INT students that may further explain the differences exhibited in the pathways described below. Additional partici­ pant demographics are in Tables 1 & Tables 2, Tables 3 Our previous research examined how cultural food insecurity influences identity and well-being in second-generation American students (Wright et al. 2021). When bringing the data from SGA and INT students together, the we found that the pathways exhibited in Figure 1 describe both populations’ experiences. However, nuances in the pathway exist between the populations. These nuances were detected in pathways 1B, 2B, and 3, including differing experiences with adaptation to U.S. foodways and identity components. Additional pathways 2D (foodways create memories), 3B (identity is tied to ECOLOGY OF FOOD AND NUTRITION 645 Table 3. Similar Themes and Illustrative Quotes from SGA and INT Participants. Research Question (RQ) 1. What is the relationship between cultural food security and identity? Theme Example quote Cultural transmission and food memories I think [sharing cultural foods] definitely makes [my identity] stronger. Whenever I, in general, get to talk about being Eritrean or the history or like the different types of food and how it’s prepared and stuff, I feel like it provides my friends with a better understanding of who I am and how I grew up. And like, what my culture looks like. And I think [sharing food] provides us with a stronger bond because it makes them know me much better because they know me that way. [Sam, SGA] I have a lot of memories of just sharing with the family and also growing up watching my mother preparing these meals. It was an experience and a part of life that can never be taken away. So, because I watched her do all these things, it became a part of life and a part of me and it’s something that I always looked forward to, and therefore I identify with that and also just the sharing plates that you know, as in a family will bring you something special and that was like something that you would always look forward to . . . so that was really, really important and I feel like I identify with that a lot. [Lisa, INT] Struggles with Americanization Sometimes I’ll eat a lot of other kinds of foods that I’m not used to eating. And I feel like I’m losing my identity. Like I’m meshing and mixing into another culture and becoming more Americanized. And it’ll be like a lot of fast foods . . . Being Mexican-Guatemalan-American, I want to eat the food that comes from the countries that my parents come from. It allows me to connect with them and my culture more. I feel like now there’s just not enough to connect me back there. So I just feel American. [Jennifer, SGA] Latin people don’t trust colonizers, and for that reason, we don’t trust Americans. Like, [Americans] became the colonizers of the colonized and have a longstanding history of killing and colonizing populations. So like I don’t want to be American or seen as American. I’m Brazilian. [Fernanda, INT] RQ2. What is the relationship between foodways, identity, and well-being? The role of identity in well-being I struggle with how I show my culture on the outside. I feel personal guilt. It is something that bothers me. I wish I could do more to uphold my identity. I wish my own performance of my identity felt real. But not speaking my language has really been degrading. I can feel it happening, and there isn’t much I can do about it. It’s very alone and like isolating . . . like imposter syndrome. [Daniel, SGA] When I think of my home country, my family, and friends, for me, the joy I feel in my heart, like wow. I just think of my mother and my grandmothers’ house. It warms me up inside. It’s like I’m experiencing this beauty and this goodness, even though I’m out here. [Lisa, INT] Connecting foodways, identity, and well- Not being able to cook my cultural foods is kind of disappointing and being sad. It impacts both my identity and well-being. It adds onto my depression. Being able to access those foods connects me back to my family. [Angel, SGA] It is because the way we carry out cultural food traditions – how we manage food, the particular foods that we eat, how much we eat, how we prepare them – are all aspects of the type of behaviors that uniquely identify us from other cultural groups. These behaviors define who we are and what groups we belong to. [Flora, INT] Foodways’ influences on physical, Sharing foods makes me feel great and wonderful. I don’t know where emotional, and mental well-being I learned it from, but I always believed in sharing what makes you happy, right. So for me, food makes me very happy, so I like to share foods. I feel very happy and very excited to share my foods. Yeah, it is a little bit of warmth. A very blissful feeling, I guess. It’s a little bit of a calming sense of meaning. [Cloud, SGA] When I’m cooking, it makes me feel happy and more calm. I usually play Iranian songs, so it’s kind of a meditation for me. Because now that everything has changed, I can have this part for myself and connect to my family back home. So it makes me calm, makes me feel kind of more in control. [Elizabeth, INT] 646 K. E. WRIGHT ET AL. memories), and 3C (memories influence well-being) were added to the con­ ceptual model to explain the students’ food experience further as indicated by the dotted arrows and dashed line in Figure 1. The arrows in the conceptual framework indicate the theorized relationships between the concepts. The dashed line represents two concepts (identity and memories) that appear to be strongly interconnected, rather than a theorized directional relationship. Similarities between INT and SGA students can be found in Table 4, and the differences between the two populations are described below. The study findings are organized into five sections shown in Figure 1; participant demographics, cultural food insecurity and well-being [pathway 1B], foodways and food identity [pathway 2B], foodways’ influence on wellbeing [pathways 2C & 3], and identity. A presentation of themes and sub­ themes are located within each section. Similarities in themes between the two populations, along with illustrative quotes, are presented in Table 4. Cultural food insecurity and well-being – Pathway 1B SGA and INT students mentioned that Reno and the University of Nevada, Reno had limited to no availability of cultural foods. Similar to SGA students (Wright et al. 2021), INT students reported feelings of emotional discomfort when they experienced cultural food insecurity. As Alpha explained, You struggle with going out without the food that you eat. You struggle with the fact that you can’t eat the foods you want and make the best, make the most of what is available. So emotionally, at times, I am uncomfortable. It’s some­ times exhausting for me. So at times, you’re not interested in eating at all . . . sometimes I just have tea and milk instead of eating. [Alpha, INT] However, because the INT students are globally diverse, they often reported having more difficulty finding their cultural foods than the SGA students. INT students expressed that it was mentally taxing trying to collect cultural foods. It’s so straining just thinking about where to buy food and thinking how do I get there? How much time do I have? How much it’s going to cost? You know, it’s like you have to budget all of these things in your mind, including the campus escort schedule, like where they’re going and what time. So, you’re like, okay, I need to make sure that I’m narrowing down just specifically what I can get from each store, specifically, where can I buy my cheese? Where can I buy organic bananas? Where can I buy this? So, it is mentally straining and really, really taxing. [Lisa, INT] Though INT students mentioned that even when cultural foods were avail­ able, they often were not accessible because they were very costly. One INT student mentioned that she had to choose between her cultural foods and what she could afford, You know, when I have to pay rent, I have to pay tuition and fees every semester. I have to pay some medical bills. I have to pay for many things. That, of course, ECOLOGY OF FOOD AND NUTRITION 647 when I go to the supermarket, I cannot give myself the opportunity to buy the foods that I want. Because often I have to choose between what I want and what I can afford. And most of the time, I can’t purchase my culture’s foods. Instead, I have to go and purchase the cheapest things that I can find. [Luna, INT] SGA students reported cultural food shock feelings when moving from a culturally dissimilar region compared to Reno (Wright et al. 2021). Comparatively, some INT students who had mentally prepared them­ selves for cultural food loss still expressed feelings of culture shock. Fernanda said that not having access to her cultural foods was so challenging that she almost moved back to her home country. While she said that things are now feeling a little better, she still feels the effects of cultural food stress and unfamiliarity with American culture. Not having my foods, initially, was very challenging. My first semester, it was hard, especially. I was like having a breakdown thinking what was I doing here because all my friends are back home happy living their lives, but I’m here, yeah. I’m going after something I want, but I’m not really happy. I’m getting better, but at first, I was like this is gonna be the same as being home, just a different language, but I now know it’s not. [Fernanda, INT] Cultural food insecurity impeded both INT and SGA students’ ability to prepare, share, and consume their cultural foods. Cultural foods were often expensive and hard to find, particularly for INT students, as their cultural foods had to be imported from across the globe. Unlike SGA students, grocery shopping and cultural food acquisition for INT students added additional stressors as they were unfamiliar with navigating the U.S. food systems. Table 4 Interview Questions (A) Background Questions Question 1: How long have you been living in the United States? Nevada? Probes: • Have you lived in any other countries or states? • Have you had the opportunity to travel within the US or other countries in your lifetime? Where have you visited? For work, school, or leisure? • Where do your parents and siblings live? • What made you choose to come to [the university]? [Probe: Do you have family here or know someone who lives nearby? Did the financial package offered by the University help in your decision? Is the academic program nationally known?] Question 2: You mentioned that you identify as [see identities listed on screener]. Are there other identities would you say that you have? [Probe: religious/gender] Probes: • How does food play a role in your identities? • At school or in Reno, are you able to get together/socialize with others that share these same identities? What do you typically do when you are together? Question 3: Now, thinking about these identities, how would you define identity? • Probe: For example, are there any qualities, beliefs, personality, looks, and/or expressions that make a person or group? (Continued) 648 K. E. WRIGHT ET AL. Table 4 (Continued). (B) Food Experience Questions Question 4: Tell me about the cultural foods that are important to you; what meaning do they have? Probe: Is food an important part of your culture and/or identity? How does food influence your identity? Of the identities listed above – where does food matter most? Question 5: I’m particularly interested in foods that are tied to one’s culture. Could you please write down [provide the interviewee with a paper and pen] some foods that are important food staples for your culture? Question 6: You listed some of (foods from question 4) as staples, from this list: Probes: • Which are your favorite? Your least favorite? (Why? – Is there a story behind how they became your favorite and least favorite?) • Are there any emotional ties to these foods? [Probes: for example, did you make with a particular family member? Are these everyday foods or foods for a special occasion?] • What do you mentally picture when you think about these foods? (Who is there? Where is it? How are they prepared? Who prepared the foods?) • Is it important for you to uphold these traditions? • How are these foods prepared? • Are there any other cultural foods that are not staples but are some of your favorite foods? • Is there a particular meal that is special or important to you in any way? Question 7: Think about some foods that are made for special occasions. What do you see and hear when you think about some of these foods? Probes: • What is the significance behind these foods? [For example: is there a historical story surrounding these foods?] • How are these foods prepared? • What do you mentally picture when you think about these foods? (Who is there? Where is it? How are they prepared? Who prepared the foods?) • Is it important for you to uphold these traditions? • Is there a memory that stands out to you when you think about these foods? Question 8: Can you describe how you feel when you eat and make (the foods mentioned previously)? • Probe: Is it important for you to eat these foods consistently? (Why or Why not?) Question 9: Are you able to prepare these foods with friends or family here in Reno? Probes: • Yes: How do you feel when you’re sharing these foods? Does this have any effect on your identity and wellbeing? How so? • Have you needed to modify the meal or ingredients for these meals? If yes, please provide more information about it. • No: How does it make you feel not to be able to share these foods? Does this have any effect on your identity and well-being? How so? Question 10: How do the foods you eat say anything about you as a person? • [Example: More expensive foods vs. less expensive foods?] Question 11: Has there been a time when you could not access or purchase the cultural foods you mentioned earlier? YES Probes: • Can you take me back to that time when you were experiencing cultural food loss? What types of food were you consuming before and after? • Were there any foods in particular that you need/wanted and had trouble affording or accessing? • Do you remember how you were feeling both physically and emotionally during that time? Did you have feelings of fatigue, anxiety, depression, etc.? • Can you explain why you may have been feeling that way? • Did this have any effect on your identity? Did you still feel connected to your culture? Was that feeling strengthened/weakened/the same? NO Probes: • How are you able to access your cultural foods? The grocery store? From family? From friends? Question 12: Are there any particular meals that you miss/missed eating regularly/from back home? Probe: Have you been/Were you able to find any adequate type of substitutes for those foods/meals? Question 13: We have talked about the connection that you have with your cultural foods. How does your food experience, such as your ability to purchase, prepare, and consume your cultural foods, affect your well-being? Question 14: How would you describe the cultural variety and availability of cultural foods on campus? Probes: • How does this make you feel? • What do you wish it looked like? ECOLOGY OF FOOD AND NUTRITION 649 Traditional foodways and food identity – Pathway 2B Cultural foods are essential to one’s cultural and ethnic identity, especially one’s collective, familial, regional, and religious identity. When cultural food security (i.e., cultural food access, availability, and quality) was present, INT and SGA students could utilize their cultural foods and foodways through preparation, sharing, and consumption (PSC). Both SGA and INT students mentioned that performing traditional food­ ways was an act of cultural transmission between cultural group members. They could unearth and carry out cultural norms, cultural traditions, cultural history, and connect to and understand their familial roots (Wright et al. 2021).Furthermore, both student populations highlighted the importance of mealtimes to bond with friends and family. Compared to SGA students, INT students highlighted that the culture of family mealtimes was naturally ingrained into societal norms and policies in their home countries. It’s a huge difference in Brazil compared to the United States. We are a lot more family-oriented, and we do most of our gatherings with our family. So food is very important for us to keep our family together. So in Brazil and most countries of Latin America, you always see families having lunch together on Saturdays, on Sundays. We have very different labor laws in Brazil, which allow us to have meals with our families or at home every day. And I believe it is very important and not only to keep family together. I believe because we have this opportunity to go home every day to have our main meals, our familial bonds are much stronger than in the U.S. [Luna, INT] Family mealtimes were so crucial for some INT students that some believed that “mealtimes are the most important part of our culture and identity” [Elnoor, INT]. Flora explained this concept by saying, It is because the way we carry out cultural food traditions – how we manage food, the particular foods that we eat, how much we eat, how we prepare them – are all aspects of the type of behaviors that uniquely identify us from other cultural groups. These behaviors define who we are and what groups we belong to. [Flora, INT] Thus, these cultural food traditions (i.e., foodways or cultural food PSC) created a “food identity” in both student populations. The students’ food identity was tied to the entire mealtime experience, such as the music playing, the teasing of friends and family, and laughter. Jack described his food identity by saying, “it’s both my parents in the kitchen, helping each other. It’s the kids putting the utensils and dishes on the table; it’s the entire family preparing everything together, it’s a cousin lighting up the fire. It all defines my identity” [Jack, INT]. Mealtimes created a sensory experience so strong for INT stu­ dents that discussing cultural foods instantly transported them right to the food memories [pathway 2D] and brought happiness [pathway 3C]. 650 K. E. WRIGHT ET AL. I feel like I can almost taste the food. It’s weird. Like I can visualize like what I would usually get like my plate of food or the tables set out. I can hear my grandma in the kitchen cooking and my dad saying, ‘come on stop cooking! Let’s sit down, let’s eat, and have a good time. Just thinking about it makes me really happy.” [Fernanda, INT] Traditional harvesting, consumption, and utilization practices (i.e., tradi­ tional food security) were also deeply embedded into the INT students’ memories [pathway 2D] and tied to their cultural identity [pathways 2A and 2B]. Because the food is so organic, we would wake up in the morning, and my grandmother would say ‘follow me to the farm,’ and she would go and chop down this big bunch of bananas, and we would sit down, and she would peel the bananas and show us how she’s going to steam them. She’d then use the banana leaf, which is like this mighty leaf. Then just pound it together and fold it so well. Then she would bake it. So, because I watched her do all these things, it became a central part of me and my cultural identity. [Lisa, INT] Both SGA and INT students were not often able to carry out traditional foodways while away at college. Many INT students mentioned that they used video chat technology to maintain traditional foodways with their families. However, as Julia mentioned, it still differs from being physically together with her family, Like I’ll get my grandmother and my mom on Skype. We try to cook and eat together through Skype. And we do it all together honestly. Like we’re there for three hours cooking and eating together. But since the ingredients are not the same, the taste is not the same, and maybe the fact that I like Mexican food so much is that it’s more about the family and everything about sharing. [Julia, INT] It is also important to note that religion also influences food traditions and dietary habits. Cultural food security impacted religious foodways for three INT partici­ pants. Two participants identified as Muslim, and one identified as Catholic. Muslims consume halal foods, which are foods that may be consumed under Islamic dietary guidelines. On-campus and in Reno, halal foods were hard to find. For the two Muslim students, eating haram foods (i.e., prohibited foods) was not an option. The limited access and availability of halal foods created anxiety for these students. Eating out at restaurants and going grocery shopping causes anxiety. When I go shopping, I have to go through all the ingredients and see if there is something that I cannot eat, and I would look for complications. So when I went go to a place which I know is halal, the food that I have and that I’m really familiar with, it feels great. I don’t think I have to think about if there is pork or not, for example. [Elnoor, INT] ECOLOGY OF FOOD AND NUTRITION 651 When cultural food sec...