Community-based prevention leads to an increase in condom use and a reduction in sexually transmitted infections (STIs) among men who have sex with men (MSM) and female sex workers (FSW): the Frontiers Prevention Project (FPP) evaluation results

Background

India has an estimated 2.0 million to 3.1 million people living with HIV; it has the highest number of HIV-positive people in Asia and ranks third in the world. The Frontiers Prevention Project (FPP) was implemented in 2002 to conduct targeted prevention intervention geared towards female sex workers (FSW) and men who have sex with men (MSM) in the state of Andhra Pradesh (AP). This paper reports the overall changes in behaviour and STI outcomes between 2003/4 and 2007 and also describes the changes attributed to the FPP.

Methods

The evaluation used two cross-sectional surveys among MSM and FSW at 24 sites in AP. Surveys were implemented using a similar methodology. Univariate analyses were conducted by comparing means: baseline vs. four-year follow-up and FPP vs. non-FPP. For both MSM and FSW, random and fixed-effects logit regression models at the site level were estimated for condom use with last partner, syphilis sero-positivity and HSV 2 sero-positivity. In addition, for FSW we estimated models for condom use with regular partner, and for MSM we estimated models for condom use with last female partner.

Results

Among MSM, fixed-effects analysis revealed that FPP was positively correlated with the probability of condom use with last female sexual partner and negatively correlated with the individual probability of sero-positivity to syphilis and HSV 2. Among FSW, the FPP intervention was significantly correlated with increased condom use with regular partners and with lower probability of STI sero-positivity.

Discussion

Important changes in behaviours related to an increase in prevention activities translated to reductions in STI sero-prevalence in AP, India. In contrast with non-FPP sites, the FPP sites experienced an intense community approach as part of the FPP intervention, and the general increase in condom use and its effect on STI sero-prevalence reflected the efficacy of these intense prevention activities focused on key populations in AP.

     

Age and IQ Explained Working Memory Performance in a RCT with Fatty Fish in a Group of Forensic Inpatients

Objectives

To investigate the effect of a long-term fatty fish intervention on a pure cognitive mechanism important for self-regulation and mental health, i.e. working memory (WM), controlling for age and IQ.

Design

A randomized controlled trial.

Setting

A forensic facility.

Participants

Eighty-four young to middle aged male forensic inpatients with psychiatric disorders.

Intervention

Consumption of farmed salmon or control meal (meat) three times a week during 23 weeks.

Measurement

Performance on WM tasks, both accuracy and mean reaction time, were recorded pre and post intervention.

Results

Performance on a cognitive functioning tasks taxing WM seemed to be explained by age and IQ.

Conclusion

Fatty fish consumption did not improve WM performance in a group of young to middle aged adults with mental health problems, as less impressionable factors such as aging and intelligence seemed to be the key components. The present study improves the knowledge concerning the interaction among nutrition, health and the aging process.

     

Implementing guidelines in primary care: can population impact measures help?

Background

Primary care organisations are faced with implementing a large number of guideline recommendations. We present methods by which the number of eligible patients requiring treatment, and the relative benefits to the whole population served by a general practice or Primary Care Trust, can be calculated to help prioritise between different guideline recommendations.

Methods

We have developed measures of population impact, "Number to be Treated in your Population (NTP)" and "Number of Events Prevented in your Population (NEPP)". Using literature-based estimates, we have applied these measures to guidelines for pharmacological methods of secondary prevention of myocardial infarction (MI) for a hypothetical general practice population of 10,000.

Results

Implementation of the NICE guidelines for the secondary prevention of MI will require 176 patients to be treated with aspirin, 147 patients with beta-blockers and with ACE-Inhibitors and 157 patients with statins (NTP). The benefit expressed as NEPP will range from 1.91 to 2.96 deaths prevented per year for aspirin and statins respectively. The drug cost per year varies from €1940 for aspirin to €60,525 for statins. Assuming incremental changes only (for those not already on treatment), aspirin post MI will be added for 37 patients and produce 0.40 of a death prevented per year at a drug cost of €410 and statins will be added for 120 patients and prevent 2.26 deaths per year at a drug cost of €46,150. An appropriate policy might be to reserve the use of statins until eligible patients have been established on aspirin, ACE-Inhibitors and beta blockers.

Conclusions

The use of population impact measures could help the Primary Care Organisation to prioritise resource allocation, although the results will vary according to local conditions which should be taken into account before the measures are used in practice.

     

Soluble milk proteins improve muscle mass recovery after immobilization-induced muscle atrophy in old rats but do not improve muscle functional property restoration

Objectives

Effect of 3 different dairy protein sources on the recovery of muscle function after limb immobilization in old rats.

Design

Longitudinal animal study.

Setting

Institut National de la Recherche Agronomique (INRA). The study took part in a laboratory setting.

Intervention

Old rats were subjected to unilateral hindlimb immobilization for 8 days and then allowed to recover with 3 different dietary proteins: casein, soluble milk proteins or whey proteins for 49 days.

Measurements

Body weight, muscle mass, muscle fibre size, isometric, isokinetic torque, muscle fatigability and muscle oxidative status were measured before and at the end of the immobilization period and during the recovery period i.e 7, 21, 35 and 49 days post immobilization.

Results

In contrast to the casein diet, soluble milk proteins and whey proteins were efficient to favor muscle mass recovery after cast immobilization during aging. By contrast, none of the 3 diary proteins was able to improve muscle strength, power and fatigability showing a discrepancy between the recovery of muscle mass and function. However, the soluble milk proteins allowed a better oxidative capacity in skeletal muscle during the rehabilitation period.

Conclusion

Whey proteins and soluble milk proteins improve muscle mass recovery after immobilization-induced muscle atrophy in old rats but do not allow muscle functional property restoration.

     

Perceptions of healthcare professionals on the usage of percutaneous endoscopic gastrostomy in a teaching hospital from a middle-income South East Asian country

Objective

To explore the perceptions of healthcare professionals’ (HCPs) in a South East Asian nation towards percutaneous endoscopic gastrostomy (PEG) feeding.

Design

Semi-structured, qualitative interviews.

Settings

A teaching hospital in Kuala Lumpur, Malaysia.

Participants

A total of 17 healthcare professionals aged 23-43 years, 82% women.

Results

Thematic analysis revealed five themes that represent HCPs’ perceptions in relation to the usage of PEG feeding: 1) knowledge of HCPs, 2) communication, 3) understanding among patients, and 4) financial and affordability.

Conclusion

The rationale for reluctance towards PEG feeding observed in this regions was explained by lack of education, knowledge, communication, team work, and financial support. Future studies should assess the effects of educational programmes among HCPs and changes in policies to promote affordability on the utilization of PEG feeding in this region.

     

Evaluation of a continuing educational intervention for primary health care professionals about nutritional care of patients at home

Objective

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals’ familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

Design

Observational cohort study.

Setting

10 primary health care centers in Stockholm County, Sweden.

Participants

140 district nurses/registered nurses and general practitioners/physicians working with home care.

Intervention

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

Measurements

The intervention’s effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

Results

In the intra-group analyses, statistically significant changes occurred in the IG’s responses to 28 of 32 items and the CG’s responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

Conclusion

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals’ level of knowledge about important aspects of nutritional care.

     

Protein enrichment of familiar foods as an innovative strategy to increase protein intake in institutionalized elderly

Objective

To increase the protein intake of older adults, protein enrichment of familiar foods and drinks might be an effective and attractive alternative for oral nutritional supplements (ONS). We performed a pilot study to test whether these products could help institutionalized elderly to reach a protein intake of 1.2 gram per kg body weight per day (g/kg/d).

Design

Intervention study with one treatment group (no control group). Dietary assessment was done before and at the end of a 10-day intervention.

Setting

Two care facilities in Gelderland, the Netherlands: a residential care home and a rehabilitation center.

Participants

22 elderly subjects (13 women, 9 men; mean age 83.0±9.4 years).

Intervention

We used a variety of newly developed protein enriched regular foods and drinks, including bread, soups, fruit juices, and instant mashed potatoes.

Measurements

Dietary intake was assessed on two consecutive days before and at the end of the intervention, using food records filled out by research assistants. Energy and macronutrient intake was calculated using the 2013 Dutch food composition database. Changes in protein intake were evaluated using paired t-tests.

Results

Protein intake increased by 11.8 g/d (P=0.003); from 0.96 to 1.14 g/kg/d (P=0.002). This increase is comparable to protein provided by one standard portion of ONS. The intake of energy and other macronutrients did not change significantly. At the end of the intervention more elderly reached a protein intake level of 1.2 g/kg/d than before (9 vs 4). Protein intake significantly increased during breakfast (+3.7 g) and during the evening (+2.2 g).

Conclusion

Including familiar protein enriched foods and drinks in the menu helped to meet protein recommendations in institutionalized elderly.

     

Association between body mass index and all-cause mortality among oldest old Chinese

Objectives

To examine the association between BMI and all-cause mortality in the oldest old (≥80 years).

Design

The study used a prospective cohort study design.

Setting

Chinese Longitudinal Healthy Longevity Survey (CLHLS) between 1998/99 and 2011.

Population

8026 participants aged 80 years and older were followed every two to three years.

Measurements

Body weight and knee height were measured. Height was calculated based on knee height using a validated equation. Deaths were ascertained from family members during follow-up.

Results

The mean BMI was 19.8 (SD 4.5) kg/m². The prevalence of underweight, overweight and obese was 37.5%, 10.2% and 4.4%, respectively. There were 5962 deaths during 29503 person-years of follow-up. Compared with normal weight, underweight was associated with a higher mortality risk (HRs: 1.20 (95%CI 1.13-1.27) but overweight (HR 0.89 (95%CI 0.81-0.99)) were associated with a lower risk. Obesity had a HR 0.91 (95%CI 0.78-1.05) for mortality.

Conclusion

Among oldest old Chinese, underweight is associated with an increased risk of all-cause mortality but overweight is associated with a reduced risk. Interventions to reduce undernutrition should be given priority among the oldest old Chinese.

     

Interrelationship between Diet Quality and Depressive Symptoms in Elderly

Background

Several observational studies have shown association between diet quality and depression, but few studies have explored the interrelationship between these variables.

Objective

The aim of this study was to assess the interrelationship between diet quality and depressive symptoms in elderly.

Design

Cross-sectional study.

Setting

Population based.

Participants

1,378 elderly in the city of Pelotas, Brazil.

Measurements

The diet quality was assessed by a short food frequency questionnaire and the prevalence of depressive symptoms was estimated by the abbreviated Brazilian version of the Geriatric Depression Scale (GDS). The association between diet quality and depressive symptoms was assessed using logistic regression.

Results

The prevalence of depressive symptoms was 15.3%. Elderly with low-quality diet were more likely to experience depressive symptoms, and the association was almost twice higher in males than in females (men OR = 3.8, 95% CI 1.4, 10.6; women OR = 2.1, 95% CI: 1.4, 3.3). On the other hand, depressive elderly had higher odds of consuming a low-quality diet (OR 2.4, 95% CI: 1.7, 3.8). Limitations: Self-reported data and crosssectional design limit our conclusions.

Conclusions

The choice of a low-quality diet was associated to a higher risk of depressive symptoms in elderly, and vice-versa. These results highlight the importance of encouraging the choice of healthy food habits, especially in depressed elderly, in order to promote healthy aging.

     

Validity of knee-estimated height to assess standing height in older adults: A secondary longitudinal analysis of the Mexican health and aging study

Objective

The main objective was to test the validity of height estimated by knee height in Mexican older adults, as a surrogate for standing height.

Design

Cohort study.

Setting

Data were drawn from the first and third waves of the Mexican Health and Aging Study.

Participants

Included participants were community-dwelling 50-year or older adults with measured height at baseline and in follow-up. Subjects with a lower limb fracture in the follow-up were excluded.

Measurements

Main measurements were baseline standing height and 11-year follow-up and knee-estimated height in follow-up. Population specific equations were used to estimate standing height from knee height. Comparisons between baseline standing height and knee-derived height were done with simple correlations, limits of agreement (Bland-Altman plot) and Deming regressions.

Results

A total of 136 50-year or older adults were followed-up for eleven years, with a mean age of 60. There was a positive correlation between knee-estimated height and baseline standing height of 0.895 (p<0.001) for men and of 0.845 (p<0.001) for women. Limits of agreement for men were from -6.95cm to 7.09cm and for women from -6.58cm to 8.44cm.

Conclusion

According to our results, knee-estimated height could be used interchangeably with standing height in Mexican older adults, and these results might apply also to other populations.

     

The Effect of Exercise and Social Activity Interventions on Nutritional Status in Older Adults with Dementia Living in Nursing Homes: A Randomised Controlled Trial

Objectives

Examine the effects of a 24-week exercise intervention against a social intervention on body weight, body mass index (BMI) and nutritional status in PWD living in nursing homes.

Design

Randomized controlled trial.

Participants

Ninety-one older people with dementia living in nursing homes. Interventions: Exercise (n=44) or social-based activities (n=47), taking place twice per week, for 60 minutes/session, during 24 weeks.

Measurements

Nutritional status was measured with the mini-nutritional assessment (MNA), weight and BMI.

Results

After the 24-week intervention, none of MNA (B-coeff. 1.28; 95% CI -2.55 to 0.02), weight (-0.06; -1.58 to 1.45) and BMI (-0.05; -0.85 to 0.74) differed significantly between groups after adjustment for multiplicity. In the social group, MNA significantly improved while it remained stable in the exercise group. The percentage of at-risk and malnourished patients reduced in both groups by more than 6%.

Conclusion

The results suggest that social activities have as good effects as exercise activities on nutritional status in PWD nursing home residents.

     

Predictors of frailty in old age–results of a longitudinal study

Objectives

To investigate time-dependent predictors of frailty in old age longitudinally.

Design

Population-based prospective cohort study.

Setting

Elderly individuals were recruited via GP offices at six study centers in Germany. The course of frailty was observed over 1.5 years (follow up wave 4 and follow up wave 5).

Participants

1,602 individuals aged 80 years and older (mean age 85.4 years SD 3.2, with mean CSHA CFS 3.5 SD 1.6) at follow up wave 4.

Measurements

Frailty was assessed by using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS), ranging from 1 (very fit) to 7 (severely frail).

Results

Fixed effects regressions revealed that frailty increased significantly with increasing age (ß=.2) as well as the occurrence of depression (ß=.5) and dementia (ß=.8) in the total sample. Changes in marital status and comorbidity did not affect frailty. While the effects of depression and dementia were significant in women, these effects did not achieve statistical significance in men.

Conclusion

Our findings highlight the role of aging as well as the occurrence of dementia and depression for frailty. Specifically, in order to delay frailty in old age, developing interventional strategies to prevent depression might be a fruitful approach.

     

Nutritional state predicts all-cause death independent of comorbidities in geriatric patients with coronary artery disease

Objective

To explore whether nutritional risk is associated with poor outcomes independent of complicated clinical status in older patients with coronary artery disease (CAD).

Design

Cohort study.

Setting

Patients referred for coronary angiography in West China Hospital, Sichuan University, China.

Participants

1772 patients with angiographic documented CAD whose age was above 65 years.

Measurements

Nutritional state was appraised using geriatric nutritional risk index (GNRI). Nutritional risk was defined as the GNRI below 98. The event rate of all-cause death was observed among patients with nutritional risk and those without.

Results

During a median follow-up period of 27 months, 224 patients died. Multivariate Cox regression analysis showed that nutritional risk was associated with all-cause death (adjusted hazard ratio 1.99; 95% confidence interval 1.35–2.95; P=0.001). Subgroup analysis verified the association between nutritional risk and death among patients with distinct clinical features, comorbidities, and medication. There was no interaction between nutritional risk and clinical characteristics with regard to all-cause death.

Conclusion

Nutritional state is independently associated with the risk of all-cause death in geriatric patients with CAD. Whether nutritional support in appropriate patients improves clinical outcomes deserves further investigation.

     

Early nutritional follow-up after discharge prevents deterioration of ADL functions in malnourished,independent, geriatric patients who live alone–A randomized clinical trial

Objectives

To compare the effects of two nutritional follow-up interventions with regard to preventing short-term deterioration in ADL, and to compare their effects on physical function, emotional health, and health-related quality of life.

Design

Randomized clinical trial with two intervention groups and one control group, and a follow-up period of eight weeks.

Setting

Intervention in the participants’ homes after discharge from hospital.

Participants

Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone.

Exclusion

Nursing home residents and patients with terminal illnesses or cognitive impairment.

Randomization

At discharge, the patients were assigned to one of three groups: ‘home visit’, ‘telephone consultation’, or ‘control’ group.

Intervention

Individually tailored nutritional counselling of the patient and the patient’s daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patients’ homes, or by telephone. The control group received no follow-up after discharge.

Measurements

Primary outcome: Change in ADL (Barthel-100 score) at discharge and eight weeks later.

Secondary outcomes

Change in physical performance (handgrip strength, 30-sec. chair stand test, CAS), quality of life and depression measurements (SF-36, Depression List, Geriatric Depression Score), and Avlund mobility-tiredness score (Mob-T).

Results

Two-hundred and eight participants were randomized, 73 to home visits and 68 to telephone consultations. The control group comprised 67 patients. The mean age of the participants was 86.1 years. At eight weeks after discharge, 157 completed the follow-up (home visit 52, telephone consultation 51, and control group 54). The mean age of these patients was 85.8 years. More patients in the home visit group improved or maintained their ADL (96%), compared to the telephone (75%) and control groups (72%), p<0.01. No difference was detected among the groups with regard to physical measurements, health-related quality of life, and emotional health.

Conclusion

Early nutritional follow-up after discharge, performed as home visits, prevents deterioration of ADL in malnourished, independent, geriatric patients who live alone and thereby preserves their independence.

     

Perspectives on the causes of undernutrition of community-dwelling older adults: A qualitative study

Objectives

Undernutrition is a major health concern particularly in vulnerable older adults. The present study aimed to reveal the causes of undernutrition as reported by community-dwelling older adults.

Design

Twenty-five semi-structured interviews and two focus group discussions were performed and analyzed.

Setting

Community-dwelling.

Participants

Older adults.

Measurements

A questionnaire on demographics, Short Nutritional Assessment Questionnaire 65+ and interviews on the potential causes of undernutrition.

Results

33 older adults agreed to participate in the interviews and focus groups. Our findings indicate that a wide variety of causes of undernutrition, both modifiable and non-modifiable, were mentioned by the older adults. Many modifiable causes of undernutrition were reported in the mental, social or food & appetite theme, such as poor food quality provided by meal services, the inability to do groceries, loneliness and mourning. Non-modifiable causes included, forgetfulness, aging, surgery and hospitalization.

Conclusions

This study provides guidance to better understand the underlying causes of undernutrition from an older adult’s perspective. The modifiable causes provide specific direction towards practical implications that might decrease or prevent undernutrition. Non-modifiable causes should raise awareness of an increased risk of undernutrition by health professionals in primary and secondary care, caregivers and family members.

     

A comparison of three sets of criteria for determining the presence of differential item functioning using ordinal logistic regression

Background

Several techniques have been developed to detect differential item functioning (DIF), including ordinal logistic regression (OLR). This study compared different criteria for determining whether items have DIF using OLR.

Objectives

To compare and contrast findings from three different sets of criteria for detecting DIF using OLR. General distress and physical functioning items were evaluated for DIF related to five covariates: age, marital status, gender, race, and Hispanic origin.

Research design

Cross-sectional study.

Subjects

1,714 patients with cancer or HIV/AIDS.

Measures

A total of 23 items addressing physical functioning and 15 items addressing general distress were selected from a pool of 154 items from four different health-related quality of life questionnaires.

Results

The three sets of criteria produced qualitatively and quantitatively different results. Criteria based on statistical significance alone detected DIF in almost all the items, while alternative criteria based on magnitude detected DIF in far fewer items. Accounting for DIF by using demographic-group specific item parameters had negligible effects on individual scores, except for race.

Conclusions

Specific criteria chosen to determine whether items have DIF have an impact on the findings. Criteria based entirely on statistical significance may detect small differences that are clinically negligible.

     

Nutritional Status and Frailty in Community-Dwelling Older Korean Adults: The Korean Frailty and Aging Cohort Study

Objectives

To examine the association between nutritional status and frailty in older adults.

Design

Cross-sectional study.

Setting

Community-dwelling older adults were recruited from 10 study sites in South Korea.

Participants

1473 volunteers aged 70–84 years without severe cognitive impairment and who participated in the Korean Frailty and Aging Cohort Study (KFACS) conducted in 2016.

Measurements

Nutritional status was measured using the Mini Nutritional Assessment Short Form (MNA-SF). Frailty was assessed with the Fried’s frailty index. The relationship between nutritional status and frailty was examined using the multinomial regression analysis, adjusting for covariates.

Results

Of the respondents 14.3% had poor nutrition (0.8% with malnutrition, 13.5% at risk of malnutrition). There were 10.7% who were frail, with 48.5% being prefrail, and 40.8% robust. Poor nutrition was related to a significantly increased risk of being prefrail (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.09–2.32) and frail (OR: 3.30, 95% CI: 1.96–5.54).

Conclusion

Poor nutritional status is strongly associated with frailty in older adults. More research to understand the interdependency between nutritional status and frailty may lead to better management of the two geriatric conditions.