Grief in Healthcare Chaplains: An Investigation of the Presence of Disenfranchised Grief

We examined how chaplains respond to grief and determined the prevalence of disenfranchised grief (i.e., grief that is not or cannot be acknowledged or supported by society) in healthcare chaplains. We conducted an online survey of members of the Association of Professional Chaplains. Of 3131 potential participants, 577 (18%) responded to the survey. In response to grief in the workplace, chaplains stated they would have low energy (78%), feel sad or moody (63%), feel like they had no time for themselves (44%), go through the motions (41%), and distance themselves from others (31%). As an indicator of disenfranchised grief, 21% of chaplains felt that their grief was not supported and affirmed in the workplace and 63% listed circumstances of death about which they felt very uncomfortable hearing or talking about. The results suggest that grief, and disenfranchised grief in particular, may be an important concern to address in healthcare chaplaincy.     

Between Individual Agency and Structure in HIV Prevention: Understanding the Middle Ground of Social Practice

When HIV prevention targets risk and vulnerability, it focuses on individual agency and social structures, ignoring the centrality of community in effective HIV prevention. The neoliberal concept of risk assumes individuals are rational agents who act on information provided to them regarding HIV transmission. This individualistic framework does not recognize the communities in which people act and connect. The concept of vulnerability on the other hand acknowledges the social world, but mainly as social barriers that make it difficult for individuals to act. Neither approach to HIV prevention offers understanding of community practices or collective agency, both central to success in HIV prevention to date. Drawing on examples of the social transformation achieved by community action in Australia and Brazil, this article focuses on this middle ground and its role in effective HIV prevention.In 2012, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released a report in conjunction with the International AIDS Conference in Washington, entitled “Together We Will End AIDS,” which included a section entitled “Transforming Societies.”1 At the beginning of this section, communities are placed center stage:

When affected communities help to plan and implement HIV initiatives, the demand for better and more equitable services increases, awareness of societal barriers and harmful gender norms is raised, governments are held accountable for meeting the needs of citizens and services and outcomes improve. This leads to broader social transformation, which is paramount to halt and reverse the HIV epidemic.1^(p58)

A few pages later, Wilson places community at the heart of an effective response, asserting that “nothing has ever happened in HIV that was not driven by the communities most impacted.”1^(p61) Later in the report, the importance of collectives and groups is again made explicit with reference to young people: “Young people have a unique role in reaching out to their peers, particularly in key populations at higher risk of HIV such as young people who inject drugs.”1^(p79)Although community has always played a part in HIV prevention, this explicit UNAIDS attention is welcome because it shifts attention away from an earlier almost exclusive focus on risk behaviors and vulnerable populations. It places socially related individuals that make up these communities center stage and in a manner that highlights agency, and more importantly, as we demonstrate, collective agency.Not all vulnerable populations perceive themselves as distinct communities based on the behaviors that place them and their members at risk for HIV. Nevertheless, the members of these populations all inhabit social worlds that mediate, in profound ways, their ability to confront HIV and AIDS. Heterosexual men and women, gay men, injection drug users, and sex workers are all at greater or lesser risk and more or less vulnerable depending on a host of sociocultural, political, and economic factors. These same people, as members of communities, groups, organizations, or collectives, are those who have acted to protect themselves and others from HIV and AIDS by transforming their own sexual and drug injection practices.Findings from studies around the world have documented declines in HIV transmission, and many of these studies have identified the role of communities, networks, and groups—both those infected with HIV and those affected either directly or indirectly by HIV—as one of the key factors related to the declines. Such evidence is provided for Africa from Uganda,2 Zimbabwe,2–4 Malawi,5 and South Africa.6 It also has come from several countries, including Brazil and Thailand,7–9 and from cities such as New York City; Rotterdam, the Netherlands; and Buenos Aires, Argentina and sites in Central Asia.10 Many of these studies provide rich and detailed accounts of the social and political processes involved in the collective shifts in social practices that preceded declining HIV incidence, and the role of sexual communities, kinship networks, and drug using groups in achieving these outcomes. Although the evidence for effectiveness is not conclusive (and effectiveness cannot be assessed the same way as efficacy using randomized controlled trials or other forms of experimental control),11 evidence is available. Such evidence, framed as a series of steps from HIV prevalence to national policies via measures of HIV incidence, changes in behavior, and HIV prevention programs,12 indicates more or less what has worked in particular settings at particular times. It is clear that collectives, whether they are communities, networks, or groups, are central in terms of advocating, initiating, and implementing change. However, what is not clearly stated is how communities become transformative in their practices.Following Adam’s analysis13 of the ways in which the epistemological framework, which is characteristic of biomedical individualism, bypasses the social, we aim to show how the predominant ways of framing discussion of HIV prevention, in terms of risk or vulnerability, have occluded attempts to understand how social transformation occurs. We also examine how the concept of “social drivers” attempts to offer the conceptual tools for engaging with community responses to HIV. Although such framing does not quite fulfill its promise, it points toward a potentially productive way of understanding social transformation and change. We examine the centrality of collective agency and social practice in social transformation, drawing on examples of shifts in practice in 2 contrasting countries, Australia and Brazil. These cases demonstrate public health’s capacity to engage with collective agency when it takes as its starting point neither risk nor vulnerability, but the collective agency of communities whose HIV prevention efforts are shaped by the specificities of what they value.     

Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one’s doctor about pain, limited health literacy, and reports of suboptimal patient–provider communication. Difficulty speaking English and not talking with one’s doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient–provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.     

Resource mobilization for health advocacy: Afro-Brazilian religious organizations and HIV prevention and control

Brazil’s national response to AIDS has been tied to the ability to mobilize resources from the World Bank, the World Health Organization, and a variety of donor agencies. The combination of favorable political economic opportunities and the bottom-up demands from civil society make Brazil a particularly interesting case. Despite the stabilization of the AIDS epidemic within the general Brazilian population, it continues to grow in pockets of poverty, especially among women and blacks. We use resource mobilization theories to examine the role of Afro-Brazilian religious organizations in reaching these marginalized populations. From December 2006 through November 2008, we conducted ethnographic research, including participant observation and oral histories with religious leaders (N = 18), officials from the National AIDS Program (N = 12), public health workers from Rio de Janeiro (N = 5), and non-governmental organization (NGO) activists who have worked with Afro-Brazilian religions (N = 5). The mobilization of resources from international donors, political opportunities (i.e., decentralization of the National AIDS Program), and cultural framings enabled local Afro-Brazilian religious groups to forge a national network. On the micro-level, in Rio de Janeiro, we observed how macro-level structures led to the proliferation of capacity-building and peer educator projects among these religious groups. We found that beyond funding assistance, the interrelation of religious ideologies, leadership, and networks linked to HIV can affect mobilization.     

Amplifying diffusion of health information in low-literate populations through adult education health literacy classes

Over the next decade, as literacy rates are predicted to decline, the health care sector faces increasing challenges to effective communication with low-literate groups. Considering the rising costs of health care and the forthcoming changes in the American health care system, it is imperative to find nontraditional avenues through which to impart health knowledge and functional skills. This article draws on classroom observations and qualitative interviews with 21 students and 3 teachers in an adult education health literacy class to explore the efficacy of using adult education courses to teach functional health literacy skills to low-literate populations. Data were analyzed using a combination of thematic and content analyses. Results describe the motivation of students to share information within the classroom and with friends and family outside the classroom. This article also provides several recommendations to help ensure accuracy of diffused information both within and outside of the classroom. Ultimately, this study suggests that the adult education system is in a prime position to impart functional health literacy skills to low-literate populations in the classroom. Significantly, this study demonstrates that adult education students themselves may be a powerful vehicle for health communication beyond the walls of the classroom.     

Controlling for sugar and ascorbic acid, a mixture of flavonoids matching navel oranges significantly increases human postprandial serum antioxidant capacity

Fruit and vegetable consumption reduces the risk for cardiovascular disease development. The postprandial state is an important contributor to chronic disease development. Orange flavonoids may reduce postprandial oxidation. It was hypothesized that a mixture of orange flavonoids would reduce postprandial oxidation better than a single orange flavonoid or orange sugar and ascorbic acid, but not as well as orange juice, when consumed with a typical breakfast. A placebo-controlled crossover trial (16 male and female participants, 4 treatments, 4 visits) was carried out. Treatments were placebo (ascorbic acid and sugar equivalent to orange juice); placebo plus hesperidin; placebo plus hesperidin, luteolin, and naringenin (mixture; found to have synergistic antioxidant properties in vitro in previous work); and orange juice (positive control). Serum oxygen radical absorbance capacity (ORAC), total plasma phenolics (TP), and serum lipoprotein oxidation (LO) were measured after a 12-hour baseline fast and at 1, 2, and 3 hours after sample consumption. The placebo plus mixture and orange juice groups were significantly increased in ORAC and LO lag time. Data for TP were inconsistent with ORAC and LO. Contrary to previous studies attributing the protective postprandial effect to fructose and ascorbate in other fruit trials, orange phenolic compounds contribute directly to the postprandial oxidative protection of serum, despite an inconsistent change in serum TP.     

Folic Acid does not limit endothelial dysfunction induced by ischemia and reperfusion: a human study

Nitric oxide synthase (NOS) uncoupling is a condition of increased production of superoxide anion associated with a decreased production of nitric oxide (NO) by this enzyme. Folic acid can prevent and/or reverse NOS uncoupling in the setting of diabetes, smoking, hypercholesterolemia, and nitrate tolerance. Whereas animal studies showed a protective effect of folic acid in ischemia and reperfusion (IR) injury, no study tested whether folic acid administration limits IR-induced endothelial dysfunction in humans. In a double-blind, parallel study, 20 healthy young male volunteers were randomized to receive folic acid, 10 mg/d for 7 days, or matching placebo. At the end of the treatment period, endothelium-dependent, flow-mediated dilation (FMD) of the radial artery was measured before and after IR injury (15 minutes of ischemia at the level of the brachial artery followed by 15 minutes of reperfusion). There was no difference at baseline between groups in any variable. In the placebo group, IR significantly blunted FMD (before IR, 6.7+/-1.0%; after IR, 1.5+/-1.3%, P<0.01). A similar effect was observed in the folic acid group (before IR, 6.3+/-1.1%; after IR, 2.1+/-1.0%, P=ns compared with placebo). As opposed to animal studies, high-dose folic acid does not protect the vascular endothelium from IR injury in humans.     

The Difficulty of Opening Medicine Containers in Old Age: A Population-Based Study

Objectives: To investigate elderly people’s ability to open medicine containers, and how this ability correlates to some common disorders that may cause functional or cognitive impairment.Methods: Cross-sectional study of older people age 81 years and older, from the second follow-up (1994–1996) of the Kungsholmen project, a population based study of very old people in an urban area of Stockholm, Sweden. Six hundred and four persons (mean age 86.7 years) were tested for their ability to open three types of medicine containers. The disorders studied were rheumatoid arthritis, stroke, Parkinson’s disease, cognitive impairment (measured by mini-mental state examination, MMSE) and impaired vision.Results: We found that 14% were unable to open a screw cap bottle, 32% a bottle with a snap lid, and 10% a blister pack. Female gender, higher age, living in an institution, Parkinson’s disease, rheumatoid arthritis, cognitive impairment and impaired vision were all associated with a decreased ability to open the containers. Less than half of the elderly people who were unable to open one or more of the containers received help with their medication. Among those living in their own homes only 27% received help.Conclusion: Older peoples’ ability to open medicine containers is impaired by several conditions affecting physical and cognitive functioning. Many elderly people who are unable to open medicine containers do not receive help with their medication, particularly those living in their own homes.     

Enhanced gene transfer activity of peptide-targeted gene-delivery vectors

We have evaluated the capacity of the cell-binding heptapeptide SIGYPLP to enhance transgene expression using non-viral and viral gene delivery vectors. Targeted polyplex based vectors showed good levels of DNA uptake in freshly isolated human umbilical vein endothelial cells (HUVECs) compared to untargeted controls, whilst displaying only modest increases in reporter gene activity. The targeted polyplexes showed reduced levels of DNA uptake in cells of a none endothelial origin although they mediated higher levels of transgene expression. The enhanced efficiency of transgene expression may relate to the more rapid rate of cell division. However, since in vivo application of polyplexes is compromised by instability to serum proteins, serum-resistant polyplexes (surface modified with multivalent reactive hydrophilic polymers based on poly[N-(2-hydroxypropyl)methacrylamide] (pHPMA)) were also evaluated for their ability to mediate transgene expression. Surface modification of polyplexes with pHPMA ablates non-specific cell entry, reducing levels of transgene expression, whilst the incorporation of the SIGYPLP peptide into the hydrophilic polymer resulted in restored transgene expression in all formulations tested. The technology of surface modification using pHPMA can also be applied in the context of viruses, masking receptor-binding epitopes and enabling the linkage of novel cell targeting ligands, enabling construction of a virus with receptor-specific infectivity. Retargeting of adenovirus based vectors using the same polymer-peptide construct enhanced levels of transgene expression in HUVECs to greater than 15 times that observed using parental (unmodified) virus, whilst restoring levels of transgene expression in non-endothelial cell lines tested. The use of constructs based on conjugates between hydrophilic polymers and small receptor-binding oligopeptides as agents for retargeting viral or non-viral vectors to cellular receptors represents a simple alternative to the use of antibodies as targeting ligands for cell specific gene delivery.     

Epidemiology of community-acquired pneumonia in children seen in hospital

There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0-15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14.4 (95% CI 13.4-15.4)/10,000 children per year and 33.8 (95% CI 31.1-36.7) for <5-year-olds; with an incidence for admission to hospital of 12.2 (95% CI 11.3-13.2) and 28.7 (95% CI 26.2-31.4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16.1 (95% CI 14.9-17.3) and 41.0 (95% CI 37.7-44.5) in the 0-4 years age group, whilst incidence for hospital admission was 13.5 (95% CI 12.4-14.6) and 32 (95% CI 29.1-35.1) respectively. In the <5 years age group incidence of lobar pneumonia was 5.6 (95% CI 4.5-6.8)/10,000 per year and severe disease 19.4 (95% CI 17.4-21.7)/10,000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1.50, 95% CI 1.07-2.11) and with prematurity, OR 4.02 (95% CI 1.16-13.85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.