The increasing impact of human immunodeficiency virus infections, sexually transmitted diseases, and viral hepatitis in Durham County, North Carolina: a call for coordinated and integrated services.

BACKGROUND: Durham County, North Carolina, faces high rates of human immunodeficiency virus (HIV) infection (with or without progression to AIDS) and sexually transmitted diseases (STDs). We explored the use of health care services and the prevalence of coinfections, among HIV-infected residents, and we recorded community perspectives on HIV-related issues. METHODS: We evaluated data on diagnostic codes, outpatient visits, and hospitalizations for individuals with HIV infection, STDs, and/or hepatitis B or C who visited Duke University Hospital System (DUHS). Viral loads for HIV-infected patients receiving care were estimated for 2009. We conducted geospatial mapping to determine disease trends and used focus groups and key informant interviews to identify barriers and solutions to improving testing and care. RESULTS: We identified substantial increases in HIV/STDs in the southern regions of the county. During the 5-year period, 1,291 adults with HIV infection, 4,245 with STDs, and 2,182 with hepatitis B or C were evaluated at DUHS. Among HIV-infected persons, 13.9% and 21.8% were coinfected with an STD or hepatitis B or C, respectively. In 2009, 65.7% of HIV-infected persons receiving care had undetectable viral loads. Barriers to testing included stigma, fear, and denial of risk, while treatment barriers included costs, transportation, and low medical literacy. LIMITATIONS: Data for health care utilization and HIV load were available from different periods. Focus groups were conducted among a convenience sample, but they represented a diverse population. CONCLUSIONS: Durham County has experienced an increase in the number of HIV-infected persons in the county, and coinfections with STDs and hepatitis B or C are common. Multiple barriers to testing/treatment exist in the community. Coordinated care models are needed to improve access to HIV care and to reduce testing and treatment barriers.

Spousal concordance in health behavior change.

OBJECTIVE: This study examines the degree to which a married individual's health habits and use of preventive medical care are influenced by his or her spouse's behaviors. STUDY DESIGN: Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouse's health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot. DATA SOURCE: This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis. SAMPLE: The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves. PRINCIPAL FINDINGS: We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors. CONCLUSIONS: Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures.

Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries.

People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g., depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n=13), Asia (n=7), and the Middle East (n=2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n=18), family-level (n=2), and pharmacological (n=2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and eleven preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.

Epidemiological and nutrition transition in developing countries: impact on human health and development

Whereas common infectious and parasitic diseases such as malaria and the HIV/AIDS pandemic remain major unresolved health problems in many developing countries, emerging non-communicable diseases relating to diet and lifestyle have been increasing over the last two decades, thus creating a double burden of disease and impacting negatively on already over-stretched health services in these countries. Prevalence rates for type 2 diabetes mellitus and CVD in sub-Saharan Africa have seen a 10-fold increase in the last 20 years. In the Arab Gulf current prevalence rates are between 25 and 35% for the adult population, whilst evidence of the metabolic syndrome is emerging in children and adolescents. The present review focuses on the concept of the epidemiological and nutritional transition. It looks at historical trends in socio-economic status and lifestyle and trends in nutrition-related non-communicable diseases over the last two decades, particularly in developing countries with rising income levels, as well as the other extreme of poverty, chronic hunger and coping strategies and metabolic adaptations in fetal life that predispose to non-communicable disease risk in later life. The role of preventable environmental risk factors for obesity and the metabolic syndrome in developing countries is emphasized and also these challenges are related to meeting the millennium development goals. The possible implications of these changing trends for human and economic development in poorly-resourced healthcare settings and the implications for nutrition training are also discussed.

Ethnic variations in the experiences of mental health service users in England: results of a national patient survey programme

Background: Minority ethnic groups in the UK are reported to have a poor experience of mental health services, but comparative information is scarce. Aims: To examine ethnic differences in patients’ experience of community mental health services. Method: Trusts providing mental health services in England conducted surveys in 2004 and 2005 of users of community mental health services. Multiple regression was used to examine ethnic differences in responses. Results: About 27 000 patients responded to each of the surveys, of whom 10% were of minority ethnic origin. In the 2004 survey, age, living alone, the 2004 survey, age, living alone, detention and hospital admissions were stronger predictors of patient experience than ethnicity. Self-reported mental health status had the strongest explanatory effect. In the 2005 survey, the main negative differences relative to the White British were for Asians. Conclusions: Ethnicity had a smaller effect on patient experience than other variables. Relative to the White British, the Black group did not report negative experiences whereas the Asian group were most likely to respond negatively. However, there is a need for improvements in services for minority ethnic groups, including access to talking therapies and better recording of ethnicity.

MENTAL HEALTH AND CRIMINALITY AMONG PSYCHIATRIC OFFENDERS IN SOUTHEASTERN ONTARIO

OBJECTIVES: (1) Describe the population of mentally ill offenders over whom Ontario Review Board (ORB) held jurisdiction. (2) Assess the influences of psychopathology and criminal factors on criminal career. METHOD: This study was a retrospective case series design that reviewed all offenders who were court ordered for psychiatric evaluation at Mental Health Services Site of Providence Care in Kingston, Ontario from 1993 to 2007 (N=347). Eighty five subjects were found not criminally responsible on the account of mental disorder and were included in statistical analysis (n=85). Bivariate associations between five key variables and two outcome variables, seriousness of crime and recidivism, were examined. Logistic regressions were conducted to test the role of the predictor variables on the outcome variables. RESULTS: Age and change in principal psychiatric diagnosis over time were shown to be associated with seriousness of crime. Timing of psychiatric onset, early signs of deviance and change in diagnosis were shown to be associated with recidivism. On the whole, study population did not markedly vary in their distribution of variables by the outcome variables. Regression model included timing of psychiatric onset; psychiatric history; existence of criminal associate; child abuse history; and early signs of deviance. Recidivism was shown to be predicted by early signs of deviance (OR=8.154, p<0.05). Existence of criminal associates was shown to have substantial values of odds ratio at marginal significance (OR=7.577, p=0.13). CONCLUSION: Seriousness of crime is a complex factor that could not be sufficiently predicted by any one or combinations of study variables. Recidivism is better predicted by criminality factors than psychopathology. In the future, an exploratory analysis that more broadly examines the psychopathology and criminal factors in Canadian forensic population is needed. Findings from this study have important clinical and legal implications.

A model for developing, implementing and evaluating a strategy to improve nursing and midwifery care

Background: Health care organizations world wide are faced with the need to develop and implement strategic organizational plans to meet the challenges of modern health care. There is a need for models for developing, implementing and evaluating strategic plans that engage practitioners, and make a measurable difference to the patients that they serve. This article describes the development of such a model to underpin a strategy for nursing and midwifery in an acute hospital trust. An integrated model: The processes for strategy development (values clarification, critical companionship and focus groups) are discussed, together with the development of processes for implementation, based upon a modification of the PARIHS (Promoting Action on Research Implementation in Health Services) conceptual framework. Finally, the methods for evaluating the strategy (a pre-test/post-test approach measuring the quality of nursing care, the degree to which the organization supports professional nursing care, the leadership styles of ward managers, and patient satisfaction with care) are described. Conclusion: The model is offered as one that may be of use to others who wish to develop an integrated approach to strategic change; an approach in which the development, implementation and evaluation of strategic plans are informed by the core values of nurses and midwives.

Are gatekeepers to renal services referring patients equitably?

Objective: Patients with chronic kidney disease (CKD) benefit from specialist interventions to retard progression of renal failure and prevent cardiovascular events. Certain patient groups have poor access to specialist renal services when dialysis is required. This study used a population-based laboratory database to investigate access to and timeliness of referral to renal specialists relatively early in the course of the disease.

Methods: All tests for serum creatinine and haemoglobin (Hb) A1c in Northern Ireland in a two-year period (2001 and 2002) were retrieved for 345,441 adults. Of these, 16,856 patients had at least one serum creatinine level above 150 µmol/L in 2001 not deemed to be due to acute renal failure (crude prevalence 1.42%). This cohort was followed until the end of 2002 and the differences in the time to referral to a specialist were assessed using Cox's proportional hazards regression.

Results: Diabetic patients, older patients and those living in deprived areas were significantly more likely to have serum creatinine testing, compared with non-diabetic, younger and those living in more affluent areas. Delays in referral to renal specialists for patients with raised serum creatinine levels were significantly shorter among diabetic patients, women, younger individuals, those living in rural areas, those living close to renal centres and those living in deprived areas. Overall, only 19% of diabetic patients and 6% of non-diabetic patients who had CKD had seen a renal specialist within 12 months of their index creatinine test.

Conclusion: Contrary to other diseases, disadvantaged patients do not seem to be under-investigated for renal disease compared with their more affluent neighbours and are generally referred earlier for specialist assessment. However, the absolute rate of timely specialist assessment is low. Recent changes in referral criteria for CKD will result in more referrals and will have serious resource implications. Opportunities for health gain among patients with declining renal function are being missed, particularly among the old and those living furthest from specialist centres.

An Examination of the Use of Coercion by Assertive Outreach and Community Mental Health Teams in Northern Ireland.

In mental health services over recent decades, the positive move away from hospital-based care to community-based services has entailed that people with higher levels of need are being supported by community mental health services. This paper begins by reviewing the literature on coercion in the field of community-based mental health care and treatment. It is argued that the lack of a critical understanding of the concept and how it is used by practitioners and agencies can have serious repercussions for the rights of service users. Using a quasi-experimental, longitudinal design, the authors then seek to test some of the ideas about coercion by comparing the activities of assertive outreach and community mental health teams in Northern Ireland, particularly the key ideas of perceived coercion, workers’ strategies and engagement with services. Key findings were that assertive outreach appeared to be more successful at reducing perceived coercion, minimizing the need for coercive strategies, engaging high-risk clients and reducing inpatient bed use. These findings are compared with other studies in this area. The authors also argue that there is a need for greater transparency in the way that practitioners use coercive measures and more explicit guidance is required in this crucial area of mental health practice.