“Knowing I can be helpful makes me feel good inside,it makes me feel essential”: community health care workers’ experiences of conducting a home-based rehabilitation intervention for people living with HIV in KwaZulu-Natal,South Africa

People living with HIV (PLHIV) are living longer lives on antiretroviral therapy and are prone to a wide range of disabilities. Innovative strategies are required to meet the rehabilitation needs of PLHIV, particularly in resource-poor communities where HIV is endemic and access to institution-based rehabilitation is limited. Home-based rehabilitation (HBR) is one such approach, but there is a paucity of research related to HBR programmes for PLHIV or the experiences of community care workers (CCWs) involved in these programmes. Following a four month randomised controlled trial of a HBR intervention designed specifically for PLHIV in KwaZulu-Natal, South Africa; four CCWs were interviewed. This study employed a qualitative research design, using semi-structured interviews to explore these workers’ experiences of being involved in carrying out this intervention. Participants reported how their personal development, improvement in their own health and increased feelings of self-worth enabled them to successfully implement the intervention. Participants also described a number of inhibitors, including stigma and environmental challenges related to the distances between patients’ homes, the steep terrain and the hot climate. Despite this, the participants felt empowered by acquiring knowledge and skills that enabled them to shift roles beyond rehabilitation provision. The findings of this study should be considered when employing a task shifting approach in the development and implementation of HBR interventions for PLHIV. By employing a less specialised cadre of community workers to conduct basic HBR interventions, both the relative lack of qualified rehabilitation professionals and the high levels of disability in HIV-epidemic communities can be simultaneously addressed.     

Should we listen to our clock to prevent type 2 diabetes mellitus?

The circadian clock drives a number of metabolic processes including energy intake, storage and utilization coupled with the sleep/wake cycles. Globally, the increasing prevalence of type 2 diabetes (T2DM) has become a significant international public health concern. In view of the heavy societal burden caused by diabetes, and further, to reduce its growing incidence, it is clearly essential to understand the causes of this disease and to devise more effective strategies for its treatment. Although many factors cause T2DM, this article centers on the role of circadian regulation of metabolism. The correlation between the increased occurrence of T2DM and the ubiquity of modern social pressures such as 24/7 lifestyles as well as nocturnal lighting conditions point strongly to the hypothesis that malfunctioning of circadian controls may be involved in the etiology of the illness. Nocturnal light exposure, unusual timing of food, irregular sleep/wake schedules and traveling between different time zones are some of the factors responsible for improper entrainment of the clock. Recent reports have proposed that strengthening of circadian clock functioning and proper timing of food intake could stabilize glucose homeostasis. This strategy thus represents a chronotherapeutic option for non-pharmaceutical intervention in treating T2DM patients.     

Editorial: Does Brussels listen? European health systems research in developing countries at the edge of extinction

Research into health systems all over the world has contributed to the development of new disease control strategies, modernized hospital and outpatient care, alternative financing mechanisms, cost-effective interventions and monitoring tools which resulted in improved delivery of care and public health services. But financing of such research is a problem in many European countries – particularly when the study is to be carried out outside the European Union – as it does not fall into the classical categories of basic science, medical science or development of drugs and vaccines and may not have an immediate impact on European health services. In view of this, a European programme for strengthening health systems research in developing countries (INCO-DEV) was set up by the European Commission in Brussels in 1983 which was integrated into the Science and Technology for Development programme on an increasing budget. For two decades it has facilitated high quality health systems research influencing health policies worldwide. Examples for INCO-funded projects are given below.     

What makes the dyspeptic patient feel ill? A cross sectional survey of functional health status, Helicobacter pylori infection, and psychological distress in dyspeptic patients in general practice

BACKGROUND: Dyspepsia is prevalent in about 30% of the general population in Europe, but only 25% of people with complaints consult their general practitioner. AIMS: To study the relation between the severity of dyspeptic complaints and the health status of patients presenting to the general practitioner; and the relation with patient characteristics, Helicobacter pylori infection, and psychological distress. METHODS: A cross sectional, general practice based survey of 360 unselected primary care dyspeptic patients from 92 general practices in The Netherlands was conducted. Symptom severity was measured using a validated symptom score, H pylori using a whole blood test, and psychological distress using the GHQ-12 test. Functional health status was assessed using the COOP/Wonca charts. RESULTS: Symptoms lasting more than three months and presence of relevant psychological distress were both associated with higher levels of dyspepsia. H pylori infection, frequency of symptoms, and age had no influence on dyspepsia severity. Severity of dyspepsia and psychological distress, but not H pylori infection or duration of symptoms, affected health status univariately. Dyspepsia correlated with general health, daily activities, and social activities. In logistic modelling, health status was far better predicted by psychological distress than by dyspepsia severity. CONCLUSION: The relation between dyspeptic symptom severity and health status is limited. H pylori infection relates neither to functional health status, nor to intensity of dyspepsia. Psychological distress is a major determinant of impaired health of dyspeptic patients in general practice and may be the clue to improvement of health status in many dyspeptic patients.     

How do people in prison feel about opt‐out hepatitis C virus testing?

The prison population is central to the campaign to eliminate hepatitis C virus as a public health threat. In the UK, this has led to the introduction of a national ‘opt‐out’ policy, requiring people in prison to be tested for HCV unless they decline, with a target to test 75% of those admitted. However, in a representative prison estate in the East Midlands of England (20,000 prison entrants per annum) testing rates were only 13.4%. This qualitative study explains why the rates of test uptake are so far short of target. This qualitative study examines the experiences of 45 people in prison about hepatitis C virus testing in an English category C (low security) prison. The data collection method was semi‐structured interviews. The data were coded and analysed according to the research questions, and interpretation of the data was aided by the use of a thematic network approach. The themes Fear, Insufficient Knowledge, Stigma, Privacy, Choice and Prison Life emerged as the principal barriers to test uptake. Test Uptake Facilitators that promoted testing were identified by participants and benefits presented of prison health care being a Health Farm. In order to increase hepatitis C virus test uptake, significant changes and flexibility in the timing, location, and staff deployed to test are required. Providing information to people in prison about hepatitis C virus transmission and treatment may reduce fears and enable the test uptake target to be met and sustained.     

How many drinks does it take you to feel drunk? Trends and predictors for subjective drunkenness

AIMS: To describe and model the sources of the variation and trends in the meaning of subjective drunkenness. DESIGN: Trend analyses of three cross-sectional surveys. SETTING: US general population. PARTICIPANTS: Those who report being drunk in the past year among those in the 1979, 1995 and 2000 National Alcohol Surveys. MEASUREMENTS: Number of drinks reported to feel drunk (dependent variable), past-year alcohol consumption measures, beverage preference, state drunk driving blood alcohol concentration (BAC) limit and demographics. FINDINGS: The mean reported number of drinks to feel drunk declined significantly between each survey and was significantly lower for women. Considerable variation was also found within surveys and was explained partially by available variables. Volume of alcohol and heavy drinking occasions were associated positively with the number of drinks to feel drunk. Higher educational attainment was associated negatively as was being a wine drinker, of older age, of African American ethnicity and of becoming drunk more frequently than once per month. Living in a state with a per se BAC limit of 0.08% was associated negatively in models for men. CONCLUSIONS: A substantial shift downward in the meaning of drunkenness occurred in the US between 1979 and 2000. This may be explained partly by the increase in educational attainment, the ageing of the population, the decline in per capita alcohol consumption and changes in alcohol policy towards lower BAC limits for drunk driving along with greater penalties, enforcement and awareness.     

How do you feel about...? Health outcomes in late life and self-perceptions of health and well-being

Research has shown over the years that the self-perceptions of older adults about their health and well-being may be at least as important as objective data for predicting the course of their health over time. I review a series of studies that span 30 years in which I and my colleagues have asked older adults in the community about their self-rated health and well-being across a spectrum of parameters, including self-rated health, social support, and mood (both negative and positive), and about whether their basic needs are being met. The social environment shapes perceptions of health and well-being, as does the body. Feelings, such as feelings about health and well-being, are therefore a key (but not the only) psychological-behavioral bridge between the body (genome and physiology) and society (environmental stressors and social context). Following a review of these studies, I attempt to place these perceptions of health and well-being in a social context, a context critical to understanding the consistency and strength of these studies (and others performed over many years) documenting the association between answers to the question "How do you feel about...?" and health outcomes over time.     

Fear of hypoglycaemia in patients with type 1 diabetes: Do patients and diabetologists feel the same way?

AimThis study described and compared the perception of hypoglycaemia in both patients with type 1 diabetes and diabetologists.MethodsThis was an observational cross-sectional study undertaken in France in 2011. Data for what hypoglycaemia represents and practices related to it were collected using a questionnaire completed by patients with type 1 diabetes (all > 12 years of age) and their diabetologists. Agreement between patients and physicians was evaluated by the intraclass correlation coefficient (ICC) and Gwet's coefficient (GC).ResultsA total of 485 patients were enrolled by 118 diabetologists. Half the patients thought that hypoglycaemia was always symptomatic. According to both patients and diabetologists, hypoglycaemia impaired quality of life, caused anxiety and was disturbing, especially at night. Clinical symptoms of hypoglycaemia (sweating, shakiness, anxiety) were linked to patient's age and diabetes duration. Regarding hypoglycaemia frequency, agreement was good for severe hypoglycaemia (GC: 0.61 and 0.72 for diurnal and nocturnal hypoglycaemia, respectively) and poor for mild hypoglycaemia (ICC: 0.44 and 0.40, respectively). Diabetologists correctly evaluated the impact of hypoglycaemia on quality of life, but overestimated the hypoglycaemia-induced burden and anxiety. Counteractive behaviours were frequent: 23% of patients decreased their insulin dose, 20% increased their sugar intake and 12% ate extra snacks. Diabetologists were generally aware of these measures, but not of how often patients used them.ConclusionDiabetologists and patients do not share enough information about hypoglycaemia. Fear of hypoglycaemia and counteractive behaviours should be looked for by diabetologists. Systematic advice and specially adapted education should also be provided to increase patients’ awareness of hypoglycaemia.     

“I did not feel like a mother”: The success and remaining challenges to exclusive formula feeding among HIV-positive women in Brazil

Exclusive and safe formula feeding can eliminate the risk of vertical HIV transmission due to breastfeeding. Therefore, many countries advise all HIV-positive women to avoid breastfeeding their infants. However, little research explores the experiences of women attempting to exclusively formula feed in countries with free and universal access to highly active antiretroviral therapy (HAART). This article examines the success of Brazil in supporting HIV-positive women as engage in exclusive formula feeding (EFF). We conducted in-depth interviews with 30 HIV-positive women receiving care at the primary facility for HIV/AIDS in Salvador, Brazil about their attitudes and practices related to EFF as well as challenges with adhering to EFF. All interviews were recorded, professionally transcribed and translated, and then analyzed. Our results showed that one woman reported both breastfeeding and formula feeding her infant; all others reported EFF. Postpartum counseling regarding the risk of HIV transmission through breastfeeding was the primary motivation for EFF. Challenges included difficulty reconciling their perceptions that breastfeeding is an important maternal responsibility, trouble accepting that breastfeeding can cause potential to harm their infants, confronting HIV-related stigma associated with EFF, and unexpected financial burdens due to EFF. We conclude that HIV-positive women adhered to national guidelines recommending EFF; this phenomenon has likely contributed to declining rates of vertical transmission in Brazil. Despite this success, many women experienced challenges with EFF. Greater support services may enhance Brazil's success in empowering HIV-positive women and eliminating vertical HIV transmission via breastfeeding.     

Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC,SEDAR, SEACV,SECTCV, AEC,SECPRE, SEPD,SEGO, SEHH,SETH, SEMERGEN,SEMFYC, SEMG,SEMICYUC, SEMI,SEMES, SEPAR,SENEC, SEO,SEPA, SERVEI,SECOT y AEU

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.Full English text available from: www.revespcardiol.org/en