[Active and healthy living in old age--results from a representative survey of community-dwelling senior citizens in Hamburg]

BACKGROUND: The majority of community-dwelling people 60 years and older are independent and live actively. However, there is little information about elderly persons' views on aging, health and health promotion. METHODS: Therefore, an anonymous, written questionnaire survey was performed in a representative sample of inhabitants from a section of the city of Hamburg, 60 years and older; 5 year intervals, 14 subsamples according to 7 age groups of females and males. RESULTS: Questionnaires from 950 participants (29% response) could be evaluated: mean age 71.5 years, 58% women, 34% living alone, 5% with professional healthcare needs as indicated by status according to German nursing care insurance. Senior citizens' positive attitudes towards aging and health were predominant: 69% of respondents felt young, 85% worried about loss of autonomy in old age. CONCLUSIONS: The results provide evidence indicating potential for improving health-promoting lifestyles in parts of the older population by evaluating and strengthening older persons' competencies and by considering their concerns seriously. These results provide valuable information for future plans in the public-health sector in the city of Hamburg where particular health-promoting actions for elderly persons will be considered.

[Neuromonitoring and neuroprotection in cardiac anaesthesia. Nationwide survey conducted by the Cardiac Anaesthesia Working Group of the German Society of Anaesthesiology and Intensive Care Medicine]

OBJECTIVE: The primary objective of this nationwide survey carried out in department of cardiac anesthesia in Germany was to identify current practice with regard to neuromonitoring und neuroprotection. METHODOLOGY: The data are based on a questionnaire sent out to all departments of cardiac anesthesia in Germany between October 2007 und January 2008. The anonymized questionnaire contained 26 questions about the practice of preoperative evaluation of cerebral vessels, intra-operative use of neuromonitoring, the nature und application of cerebral protective measures, perfusion management during cardiopulmonary bypass, postoperative evaluation of neurological status, and training in the field of cerebral monitoring. RESULTS: Of the 80 mailed questionnaires 55% were returned and 90% of department evaluated cerebral vessels preoperatively with duplex ultrasound. The methods used for intra-operative neuromonitoring are electroencephalography (EEG, 60%) for type A dissections (38.1%), for elective surgery on the thoracic and thoraco-abdominal aorta (34.1% and 31.6%, respectively) and in carotid surgery (43.2%) near infrared spectroscopy (40%), evoked potentials (30%) and transcranial Doppler sonography (17.5%), with some centers using combined methods. In most departments the central nervous system is not subjected to monitoring during bypass surgery, heart valve surgery, or minimally invasive surgery. Cerebral protective measures used comprise patient cooling on cardio-pulmonary bypass (CPB 100%), extracorporeal cooling of the head (65%) and the administration of corticosteroids (58%), barbiturates (50%) and antiepileptic drugs (10%). Neuroprotective anesthesia consists of administering inhalation anesthetics (32.5%; sevoflurane 76.5%) and intravenous anesthesia (20%; propofol and barbiturates each accounting for 46.2%). Of the departments 72.5% cool patients as a standard procedure for surgery involving cardiovascular arrest and 37.5% during all surgery using CPB. In 84.6% of department CPB flow equals calculated cardiac output (CO) under normothermia, while the desired mean arterial pressure (MAP) varies between 60 and 70 mmHg (43.9%) and between 50 and 60 mmHg (41.5%), respectively. At body temperatures less than 18 degrees C CPB flow is reduced below the calculated CO (70%) while 27% of departments use normothermic flow rates. The preferred MAP under hypothermia is between 50 and 60 mmHg (59%). The results of intra-operative neuromonitoring are documented on the anesthesia record (77%). In 42.5% of the departments postoperative neurological function is estimated by the anesthesiologist. Continuing education sessions pertaining to neuromonitoring are organized on a regular basis in 32.5% of the departments and in 37.5% individual physicians are responsible for their own neuromonitoring education. CONCLUSION: The present survey data indicate that neuromonitoring and neuroprotective therapy during CPB is not standardized in cardiac anesthesiology departments in Germany. The systemic use of available methods to implement multimodal neuromonitoring would be desirable.

Modernising Social Work and the Ethics of Care

Recent attempts to 'modernise' social work have emphasised the importance of collaboration, partnership, and participation with individual users of services and the wider community. However, technical-rational aspects of managerialism have proved dominant. Managerialist approaches to social service administration and delivery threaten important dimensions of social work; specifically its caring and democratic-transformative dimensions. However, social work theorists have only recently begun to re-engage with ideas of care. We argue that closer attention to feminist debates about the ethics of care can make a significant contribution to not only rehabilitating the ideal of care for social work but also to moving forward the modernisation agenda itself. We develop a feminist critique of managerialism, and argue that the discourse of the ethics of care offers useful ways of framing arguments to counter some damaging impacts of managerial reforms.

Orphanhood, Poverty and the Care Dilemma: Review of Global Policy Trends

The care and protection of children experiencing orphanhood presents a major child-care policy challenge. This paper draws on a review of the literature to document divergent conceptualizations of orphanhood, how the hurdles for the care of orphans reflect wider issues of poverty and inequality, as well as the ways in which different care interventions (familial, institutional, community-based and rights-based) might be appropriated for children in need. It is argued that the map of contemporary orphanhood overlaps with the contours of global poverty, inequality, age-based deprivations and marginalization. An example of a ‘globalised’ model of orphan care, namely SOS Children’s Villages, is presented and its implications for policy are examined. The paper highlights the significance of fighting poverty and enhancing the care-giving capabilities of extended families in the care and protection of children from a rights-based perspective. It suggests that external interventions should primarily address the structural causes of poverty and marginality, rather than amplifying inequalities through the selective support of orphans in economically vulnerable communities.

Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi

OBJECTIVE To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi. DESIGN, SETTING, AND PARTICIPANTS We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21 939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11 534). RESULTS Of the women who started ART under Option B+ (n = 21 939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350 cells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%. CONCLUSION Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.

Bringing the Community into the Classroom: Teaching Immunizations Skills via a Community-based Project

Introduction or Statement of Problem Health care profession educators are challenged in their efforts to bring clinical experiences into the class room and to introduce students to community settings early in their didactic training. An immunization program directed at improving childhood immunization rates can introduce students to the community, to students of other disciplines and reinforce the knowledge and skills needed for immunization interventions. Successful interventions increase community demand for immunizations, improve access to services, and educate providers about immunization services and disease. Interventions serve to mold attitudes among health care professionals that foster commitment to universal immunization coverage and low disease rates. [See PDF for complete abstract]

THE MULTIPLE LOCATION TIME WEIGHTED INDEX: USING PATIENT ACTIVITY SPACES TO CALCULATE PRIMARY CARE SERVICE AREAS

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering “free or low cost visits”, meeting “all of the patient’s health care needs”, and seeing “the patient quickly” were all ranked higher than geographic reasons. Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts.

Camp For All Connection: a community health information outreach project

Purpose: The purpose of the Camp For All Connection project is to facilitate access to electronic health information resources at the Camp For All facility. Setting/Participants/Resources: Camp For All is a barrier-free camp working in partnership with organizations to enrich the lives of children and adults with chronic illnesses and disabilities and their families by providing camping and retreat experiences. The camp facility is located on 206 acres in Burton, Texas. The project partners are Texas Woman's University, Houston Academy of Medicine-Texas Medical Center Library, and Camp For All. Brief Description: The Camp For All Connection project placed Internet-connected workstations at the camp's health center in the main lodge and provided training in the use of electronic health information resources. A train-the-trainer approach was used to provide training to Camp For All staff. Results/Outcome: Project workstations are being used by health care providers and camp staff for communication purposes and to make better informed health care decisions for Camp For All campers. Evaluation Method: A post-training evaluation was administered at the end of the train-the-trainer session. In addition, a series of site visits and interviews was conducted with camp staff members involved in the project. The site visits and interviews allowed for ongoing dialog between project staff and project participants.

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.

Commentary on “Connecting the Dots: Families and Children with Special Needs in a Rural Community”

Starks et al. discuss an evaluation of educational initiatives to improve rural systems of care for children with special needs. Akin to the medical home neighborhood concept, building a holistic medical "village" entails improving collaboration, sharing accountability, and helping families to navigate the health care system. The article suggests that policymakers should include patient experiences of care in program evaluation, and they should build a community infrastructure for shared information and efficient communication.

Community participation in health services

This study critically analyzes and synthesizes community participation (CP) theory across disciplines, defining and beginning to map out the elements of CP according to a preliminary framework of structure, process, intermediate outcomes, and ultimate outcomes. The first study component sought to determine the impact of Sight N' Soul, a CP project utilizing neighborhood health workers (NHWs), on appointment missing in an indigent urban African-American population. It found that persons entering the vision care system through contact with an NEW were about a third less likely to miss an appointment than those persons entering the system through some other avenue. While theory in this area remains too poorly developed to hypothesize causal relationships between structure, process, and outcomes, a summary of the elements of Sight N' Soul's structure and process both developed the preliminary framework and serves as a first step to mapping these relationships. The second component of the study uncovered the elements of structure and process that may contribute to a sustained egalitarian partnership between community people and professionals, a CP program called Project HEAL. Elements of Project HEAL's structure and process included a shared belief in the program; spirituality; contribution, ownership, and reciprocation; a feeling of family; making it together; honesty, trust, and openness about conflict; the inevitability of uncertainty and change; and the guiding interactional principles of respect; love, care, and compassion; and personal responsibility. The third component analyzed the existing literature, identifying and addressing gaps and inconsistencies and highlighting areas needing more highly developed ethical analysis. Focal issues include the political, economic, and historical context of CP; the power of naming; the issue of purpose; the nature of community; the power to muster and allocate resources; and the need to move to a systems view of health and well-being, expanding our understanding of the universe of potential outcomes of CP, including iatrogenic outcomes. Intermediate outcomes might include change in community, program, and individual capacity, as well as improved health care delivery. Ultimate outcomes include increased positive interdependencies and opportunities for contribution; improved mental, physical, and spiritual health; increased social justice; and decreased exploitation. ^

The Hamburg-Model of Integrated Care for Patients with Psychosis: Part 1

Objective: The "Hamburg model" designates an integrated care model for severely ill patients with psychotic disorders financed by the health insurance system in accordance with § 140 SGB V.Methods: It comprises comprehensive and long-term treatment within a regional network of the psychosis center of the University Medical Center Hamburg-Eppendorf (UKE) and private psychiatrists. The treatment model consists of therapeutic assertive community treatment (ACT) provided by a highly specialized treatment team and need-adapted in- and outpatient care.Results and conclusions: The present article summarizes the disease- and treatment-specific rationales for the model development as well as the model structure and treatment contents. The article further summarizes the effectiveness and efficiency results of a study comparing the Hamburg model and treatment as usual (without ACT) within a 12-month follow-up study (ACCESS trial).

Therapy of community-acquired acute bacterial meningitis: the clock is running

Despite antibiotic therapy and supportive intensive medical care, bacterial meningitis remains a disease with high mortality and morbidity. Rapid recognition of symptoms is crucial to direct physicians quickly towards appropriate diagnostic measures and, initially, empiric antibiotic therapy. It has become evident that time from arrival at the hospital to application of the first dose of antibiotics is a crucial independent factor that influences outcome. Here, we review the clinical and laboratory presentation of community-acquired bacterial meningitis and the antibiotic regiments that are currently recommended for its treatment; future therapeutic options are also discussed. Finally, suggestions for the approach to a patient with suspected bacterial meningitis are presented.

Awareness of headache and of National Headache Society activities among primary care physicians - a qualitative study

BACKGROUND Headache is one of the most common symptoms in primary care. To improve the quality of headache diagnosis and management with the largest possible benefit for the general population, headache and pain societies around the world have recently been devoting more attention to headache in primary care.The aim of the study was to investigate the potential contribution that national societies can make toward raising the awareness of primary headaches in general practice. FINDINGS In a qualitative telephone survey, targeting primary care practices (PCP), we asked about the frequency of headache patients in their practices and inquired about their treatment and referral strategies.A total of 1000 telephone interviews with PCP have been conducted. Three-hundred and fifty physicians have been directly interviewed, 95% of them see headache patients every week, 23% daily. Direct MRI referral is done by 84%. Sixty-two per cent of the physicians knew the Swiss headache society, 73% were interested in further education about headaches. CONCLUSION The survey yielded information about the physicians' awareness of the Swiss Headache Society and its activities, and about their desire for continuing education in the area of headache. National headache societies should work to improve the cooperation between headache specialists and PCP, aiming for a better care for our patients with headache.

Characteristics and comprehensiveness of adult HIV care and treatment programmes in Asia-Pacific, sub-Saharan Africa and the Americas: results of a site assessment conducted by the International epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration

INTRODUCTION HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide. METHODS Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia-Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization-recommended essential HIV services. RESULTS Most sites reported serving urban (61%; region range (rr): 33-100%) and both adult and paediatric populations (77%; rr: 29-96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services - nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother-to-child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) - were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President's Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low-HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services. CONCLUSIONS This study serves as a baseline for on-going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.