A systematic review examining the relationship between oral health care practices and the oral lesions commonly associated with HIV/AIDS, and the implications for people living in developing countries

Oral lesions, which may be bacterial, fungal or viral in nature may be characteristic of HIV/ AIDS, and have been observed on the oral mucosa as early signs of underlying disease. Some studies have suggested that there may be a correlation between poor oral hygiene, and the oral lesions seen among people living with HIV/AIDS.^ The objective of this study was to assess the nature of the relationship between oral health care practices, and the occurrence of oral lesions commonly seen in association with HIV/AIDS. A systematic review of the literature was conducted, and the databases searched were Medline and PubMed. Concepts that made up the search were oral hygiene promotion, HIV/AIDS and oral health care. Out of the 410 items identified through the search, only 11 met the inclusion criteria.^ The use of 0.12%–2% chlorhexidine gluconate, was found to be effective in reducing oral Candida counts in some studies, while other studies did not find such an association. However, 0.12%–2% chlorhexidine gluconate was consistently found to be effective in the management of periodontal lesions in people infected with HIV/AIDS. ^ Dental procedures such as treatment and filling of dental cavities, scaling and polishing, and use of fluoridated tooth paste were also found to be effective in the management of oral lesions seen in association with HIV/AIDS.^ The overall findings from the studies reviewed, suggest that effective oral health care may be necessary to reduce the morbidity, and mortality associated with the oral lesions seen among people living with HIV/AIDS. However, better designed studies with larger sample sizes need to be developed in order to ascertain the effectiveness of routine oral hygiene, and health care practices among people living with HIV/AIDS.^

Factors associated with home health care costs

Characteristics of Medicare-certified home health agencies in Texas and the contributions of selected agency characteristics on home health care costs were examined. Cost models were developed and estimated for both nursing and total visit costs using multiple regression procedures. The models included home health agency size, profit status, control, hospital-based affiliation, contract-cost ratio, service provision, competition, urban-rural input-price differences, and selected measures of patient case-mix. The study population comprised 314 home health agencies in Texas that had been certified at least one year on July, 1, 1986. Data for the analysis were obtained from Medicare Cost Reports for fiscal year ending between July 1, 1985 to June 30, 1986.^ Home health agency size, as measured by the logs of nursing and total visits, has a statistically significant negative linear relationship with nursing visit and total visit costs. Nursing and total visit costs decrease at a declining rate as size increases. The size-cost relationship is not altered when controlling for any other agency characteristic. The number of visits per patient per year, a measure of patient case-mix, is also negatively related to costs, suggesting that costs decline with care of chronic patients. Hospital-based affiliation and urban location are positively associated with costs. Together, the four characteristics explain 19 percent of the variance in nursing visit costs and 24 percent of the variance in total visit costs.^ Profit status and control, although correlated with other agency characteristics, exhibit no observable effect on costs. Although no relationship was found between costs and competition, contract cost ratio, or the provision on non-reimburseable services, no conclusions can be made due to problems with measurement of these variables. ^

Perceptions of chief executives of Texas Catholic health care institutions regarding the poor and the provision of Catholic health care

Perceptions of chief executive officers (CEOs) of Texas Catholic health care institutions regarding the poor and the provision of Catholic health care were the focus for this study. A total of 40 health care administrators were asked to participate in a survey. Thirty-seven CEOs responded, including seven religious superiors, six health system CEOs and 24 hospital CEOs. Survey items concerning Catholic health for the poor centered on obligations and responsibilities of Catholic hospitals, means of achieving those obligations, and assessment of whether hospitals' objectives were being met. In addition, respondents' attitudes and beliefs about poor people in general were examined. Independent variables were CEO type, gender, religious preference, member of a religious order, and educational preparation. For purposes of analysis, most survey items were classified by level of consensus exhibited by respondents. The respondents to this survey agreed on most issues concerning poor people and the provision of Catholic health care. However, there were areas of disagreement particularly in Part I of the survey which dealt with responsibility/obligation, means/methods, and assessment of health care delivery for the poor. ^

Cross-culture perspectives on fear of HIV disease and AIDS in health care workers

Health care workers have been known to carry into the workplace a variety of judgmental and negative attitudes towards their patients. In no other area of patient care has this issue been more pronounced as in the management of patients with AIDS. Health care workers have refused to treat or manage patients with AIDS and have often treated them more harshly than identically described leukemia patients. Some health care institutions have simply refused to admit patients with AIDS and even recent applicants to medical colleges and schools of nursing have indicated a preference for schools in areas with low prevalence of HIV disease. Since the attitudes of health care workers do have significant consequences on patient management, this study was carried out to determine the differences in clinical practice in Nigeria and the United States of America as it relates to knowledge of a patient's HIV status, determine HIV prevalence and culture in each of the study sites and how they impact on infection control practices, determine the relationship between infection control practices and fear of AIDS, and also determine the predictors of safe infection control practices in each of the study sites.^ The study utilized the 38-item fear of AIDS scale and the measure of infection control questionnaire for its data. Questionnaires were administered to health care workers at the university teaching hospital sites of Houston, Texas and Calabar in Nigeria. Data was analyzed using a chi-square test, and where appropriate, a student t-tests to establish the demographic variables for each country. Factor analysis was done using principal components analysis followed by varimax rotation to simple structure. The subscale scores for each study site were compared using t-tests (separate variance estimates) and utilizing Bonferroni adjustments for number of tests. Finally, correlations were carried out between infection control procedures and fear of AIDS in each study site using Pearson-product moment correlation coefficients.^ The study revealed that there were five dimensions of the fear of AIDS in health care workers, namely fear of loss of control, fear of sex, fear of HIV infection through blood and illness, fear of death and medical interventions and fear of contact with out-groups. Fear of loss of control was the primary area of concern in the Nigerian health care workers whereas fear of HIV infection through blood and illness was the most important area of AIDS related feats in United States health care workers. The study also revealed that infection control precautions and practices in Nigeria were based more on normative and social pressures whereas it was based on knowledge of disease transmission, supervision and employee discipline in the United States, and thus stresses the need for focused educational programs in health care settings that emphasize universal precautions at all times and that are sensitive to the cultural nuances of that particular environment. ^

HEALTH STATUS - HEALTH SERVICE RESOURCES - ECONOSOCIOCULTURAL DEVELOPMENT: IMPLICATIONS FOR HEALTH CARE POLICY IN AFRICA

Rational health services planning requires an examination of the effects of various factors on the health status of a population within a given set of socioeconomic circumstances. The commonly accepted explanations for improved health in the less developed countries (LDCs) are: Health Service Resources available to a population, Environmental and Life conditions, and the Econosociocultural Characteristics of the population.^ In the context of the low economic base from which many LDCs initiate development activities, a strong imperative exists for identifying in which of these major areas public health policy would be most effective in terms of improving health. A new conceptual model is proposed that would be used for future policy analyses to assess what changes in health status of populations in LDCs can be expected as direct functions of increased health service resources, and of improved environmental and econosociocultural conditions.^ While direct policy analysis is ill-advised at this time due to data inadequacy, the model is illustrated using data presently available for twenty-five relatively homogeneous Sub-Sahara African countries. Within the limitations of available data, study findings indicate that while econosociocultural conditions were the most important explanatory factors of the three major independent variables in 1970, health service resources became the most important in 1975. Study findings are inconclusive at this time with regards to the relative contributions of physicians and medical assistants in explaining variances in mortality in these countries.^ Because of the deficient nature of available data, study findings should be interpreted very cautiously. Tests of statistical significance of study findings were by-passed because of their situational technical inappropriateness. This study is significant in being the first of its kind and scope to focus on the Sub-Sahara African region of the World Health Organization, using the Wroclaw Taxonomic Method in conjunction with a stepwise regression technique. It is desirable, therefore, to examine the observed magnitude and directional consistency of all hypothesized relationships, even if evidence is inconclusive. ^

HEALTH CARE COST INCREASES IN METROPOLITAN AREAS

The research project is an extension of the economic theory to the health care field and health care research projects evaluating the influence of demand and supply variables upon medical care inflation. The research tests a model linking the demographic and socioeconomic characteristics of the population, its community case mix, and technology, the prices of goods and services other than medical care, the way its medical services are delivered and the health care resources available to its population to different utilization patterns which, consequently, lead to variations in health care prices among metropolitan areas. The research considers the relationship of changes in community characteristics and resources and medical care inflation.^ The rapidly increasing costs of medical care have been of great concern to the general public, medical profession, and political bodies. Research and analysis of the main factors responsible for the rate of increase of medical care prices is necessary in order to devise appropriate solutions to cope with the problem. An understanding of the community characteristics and resources-medical care costs relationships in the metropolitan areas potentially offers guidance in individual plan and national policy development.^ The research considers 145 factors measuring community milieu (demographic, social, educational, economic, illness level, prices of goods and services other than medical care, hospital supply, physicians resources and techological factors). Through bivariate correlation analysis, the number of variables was reduced to a set of 1 to 4 variables for each cost equation. Two approaches were identified to track inflation in the health care industry. One approach measures costs of production which accounts for price and volume increases. The other approach measures price increases. One general and four specific measures were developed to represent each of the major approaches. The general measure considers the increase on medical care prices as a whole and the specific measures deal with hospital costs and physician's fees. The relationships among changes in community characteristics and resources and health care inflation were analyzed using bivariate correlation and regression analysis methods. It has been concluded that changes in community characteristics and resources are predictive of hospital costs and physician's fees inflation, but are not predictive of increases in medical care prices. These findings provide guidance in the formulation of public policy which could alter the trend of medical care inflation and in the allocation of limited Federal funds.^

The relationship between obesity, autoimmune disease, and C-reactive protein: A secondary data analysis of the National Health and Nutrition Examination Survey (NHANES) 2009--2010

Autoimmune diseases are a group of inflammatory conditions in which the body's immune system attacks its own cells. There are over 80 diseases classified as autoimmune disorders, affecting up to 23.5 million Americans. Obesity affects 32.3% of the US adult population, and could also be considered an inflammatory condition, as indicated by the presence of chronic low-grade inflammation. C-reactive protein (CRP) is a marker of inflammation, and is associated with both adiposity and autoimmune inflammation. This study sought to determine the cross-sectional association between obesity and autoimmune diseases in a large, nationally representative population derived from NHANES 2009–10 data, and the role CRP might play in this relationship. Overall, the results determined that individuals with autoimmune disease were 2.11 times more likely to report being overweight than individuals without autoimmune disease and that CRP had a mediating affect on the obesity-autoimmune relationship. ^

Economic evaluation of latent tuberculosis infection screening among health care workers in Houston

Since interferon-gamma release assays (IGRAs) were introduced in the 2000's, tuberculin skin testing (TST) and IGRAs have been used in various latent tuberculosis infection (LTBI) screening settings. IGRAs are laboratory-based tests and are considered not to be affected by previous Bacille de Calmette et Guérin (BCG) vaccination; however, they are more costly when compared directly with TST, which does not require specimen processing in a laboratory. This study aimed to examine TST and two types of IGRAs, QuantiFERON-TB Gold in Tube (QFT-GIT) and T-SPOT. TB (TSPOT), from an economic viewpoint. Firstly, a systematic literature review was conducted to identify cost related analyses of LTBI screening. Secondly, specific cost information detailing each test's items and labor was collected from an LTBI screening program of health care workers in Houston, and the cost of each test was computed. Thirdly, using the computed cost estimate of each test, cost-effectiveness analyses were conducted to compare TST and IGRAs.^ A literature search showed that a limited number of studies have been conducted, but the IGRA's economic advantages were common among studies. Cost analyses showed that IGRAs were much more costly than TST. The results were consistent with previous studies. In cost-effectiveness analyses, where test cost and consequential TB-related cost were considered, IGRAs showed variable advantages over TST depending on the targeted population. When only non BCG-vaccinated people were considered, TST was the least costly option among the three tests. On the other hand, when only BCG-vaccinated people were considered, IGRAs were less costly options. These results were mostly consistent even with varying assumption parameters.^ IGRAs can be more costly than TST, but their economic disadvantages are alleviated when the target population was BCG-vaccinated. Based on current knowledge, IGRAs may be recommended in a population where the BCG history is mixed. Additional studies are needed to better understand IGRA's reliability among low-incidence and low-risk populations in which background TB prevalence is low.^

Shifting the focus: Addressing breast cancer disparities at the health care organization level

The purpose of this study was to understand the scope of breast cancer disparities within the Texas Medical Center. The goal was to increase the awareness of breast cancer disparities at the health care organization level, and to foster the development of organizational interventions to reduce breast cancer disparities. The study seeks to answer the following questions: 1. Are hospitals in the Texas Medical Center implementing interventions to reduce breast cancer disparities? 2. What are their interventions for reducing the effects of non clinical factors on breast cancer treatment disparities? 3. What are their measures for monitoring, continuously improving, and evaluating the success of their interventions? ^ This research project was designed as a mixed methods case study. Quantitative breast cancer data for the years 2000-2009 was obtained from the Texas Cancer Registry (TCR). Qualitative data collection and analysis was done by conducting a total of 20 semi-structured interviews of administrators, physicians and nurses at five hospitals (A, B, C, D and E) in the Texas Medical Center (TMC). For quantitative analysis, the study was limited to early stage breast cancer patients: local and regional. The dependent variable was receipt of standard treatment: Surgery (Yes/No), BCS vs Mastectomy, Chemotherapy (Yes/No) and Radiation after BCS (Yes/No). The main independent variable was race: non-Hispanic White (NHW) , non-Hispanic Black (NHB), and Hispanic. Other covariates included age at diagnosis, diagnosis date, percent poverty, grade, stage, and regional nodes. Multivariate logistic regression was used to test the adjusted association between receipt of standard care and race. Qualitative data was analyzed with the Atlas.ti7 software (ATLAS.ti GmbH, Berlin). ^ Though there were significant differences by race for all dependent variables when the data was analyzed as a single group of all hospitals; at the level of the individual hospitals the results were not consistent by race/ethnicity across all dependent variables for hospitals A, B, and E. There were no racial differences in adjusted analysis for receipt of chemotherapy for the individual hospitals of interest in this study. For hospitals C and D, no racial disparities in treatment was observed in adjusted multivariable analysis. All organizations in this study were aware of the body of research which shows that there are disparities in breast cancer outcomes for patient population groups. However, qualitative data analysis found that there were differences in interest among hospitals in addressing breast cancer disparities in their patient population groups. Some organizations were actively implementing directed measures to reduce the breast cancer disparity gap in outcomes for patients, and others were not. Despite the differences in levels of interest, quantitative data analysis showed that organizations in the Texas Medical Center were making progress in reducing the burden of breast cancer disparities in the patient populations being served.^

Attitudes of health-care workers toward pregnant, HIV -positive women

The management of HIV infection with antiretroviral drugs has succeeded in increasing survival rates, but the subject of pregnancy in HIV-positive women continues to garner debate. Discrimination and stigma have been identified as barriers to health care, suggesting that women with HIV may be disinclined to seek prenatal care if health-care workers exhibit negative attitudes toward the women's pregnancies. To optimize prenatal and medical care for women with HIV infection, it is important to understand the general social conditions and cultural context in which these women have children. Goffman's treatise on stigma, Foucault's discussion of the knowledge/power matrix, and Bandura's Social Cognitive Theory offer theoretical perspectives by which we can evaluate the gender, race, and class issues that are inherent in pregnancy decision-making for women with HIV infection. It is also necessary to evaluate prevailing attitudes on childbearing toward HIV-positive women and to review the historical background of prejudice in which HIV-positive women make decisions regarding childbearing. ^ This qualitative study used a survey instrument and one-on-one interviews with HIV-infected women to elicit their perceptions of how they were treated by care providers when they became pregnant. It also included interviews with health-care workers to determine what their feelings are about pregnancy within the context of HIV infection. Results of the ethnographic inquiry reveal that most of the women had negative experiences at some point during a pregnancy, but that the situation improved when they sought care from a provider who was familiar with HIV infection. The health-care providers interviewed were firm in their belief that HIV-positive women deserved optimal care and treated the women with respect, but these are individuals who are also experts in providing care to HIV-positive patients. The question remains as to what kind of care HIV-positive women are receiving generally and what types of attitudes they are being subjected to if they see less experienced providers. Further research is also needed to determine whether HIV-positive women from a broader ethnic representation and higher socioeconomic status experience similar negative attitudes. ^

Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene

Human trafficking is a complex and multifaceted problem that takes the form of economic, physical and sexual exploitation of people, both adults and children, who are reduced to simple products for commerce. Human trafficking in the United States also has both a domestic and an international aspect. Health care providers are in a unique position to screen for victims of trafficking and may provide important medical and psychological care for victims while in captivity and thereafter. Trafficked persons are likely to suffer a wide spectrum of health risks that reflect the unique circumstances and experiences in a trafficked victim’s life. Although trafficked victims typically have experienced inadequate medical care, once contact is made by the victim with the health care professionals, the opportunity then exists to identify, treat, and assist such victims. The range of services and supports required to appropriately respond to human trafficking victims once identified is broad and typically goes beyond just what is immediately provided by the health care professional and includes safe housing, legal advice, income support, and, for international victims, immigration status related issues. An informed and responsive community is necessary to serve both the international and domestic victims of human trafficking, and needs assessments demonstrated a number of barriers that hindered the delivery of effective services to human trafficking victims. One of the consistent needs identified to combat these barriers was enhanced training among all professionals who might come in contact with human trafficking victims. We highlight the efforts of the Houston Rescue and Restore Coalition (HRRC), a local grassroots non-profit organization whose mission focuses on raising awareness of human trafficking in the Greater Houston Metropolitan area. HRRC responded to the consistent recommendation from various community needs assessments for additional training of front line professionals who would have the opportunity to identify human trafficking victims and supported the design and pilot testing of a health professions training program around human trafficking. Dissemination of this type of training along with careful evaluation and continued refinement will be one way for health care professionals to engage in a positive manner with human trafficking victims.