The experience of re-infection among people who inject drugs successfully treated for hepatitis C.

INTRODUCTION: Highly effective direct-acting antiviral (DAA) agents have changed the landscape of hepatitis C virus infection (HCV) treatment and have become more available to people who inject drugs (PWID) over the past several years. Although many achieve a sustained virologic response (SVR), a small proportion will become re-infected. This study examined experiences of re-infection among participants in Project HERO, a large multi-site treatment trial designed to test alternative treatment delivery models for DAAs. METHODS: Study staff conducted qualitative interviews with twenty-three HERO participants who experienced reinfection following successful treatment for HCV. Interviews focused on life circumstances and experiences with treatment/re-infection. We conducted a thematic analysis, followed by a narrative analysis. RESULTS: Participants described challenging life circumstances. The initial experience of cure was joyful, leading participants to feel that they had escaped a defiled, stigmatized identity. Re-infection was very painful. Feelings of shame were common. Participants with fully developed narratives of re-infection described both a strong emotional response as well as a plan for avoiding re-infection during retreatment. Participants who lack such stories showed signs of hopelessness and apathy. CONCLUSION: Though the promise of personal transformation through SVR may be motivating for patients, clinicians should be cautious about how they describe the "cure" when educating patients about HCV treatment. Patients should be encouraged to avoid stigmatizing, dichotomizing language of the self, including terms such as "dirty" and "clean." In acknowledging the benefits of HCV cure, clinicians should emphasize that re-infection does not mean failed treatment; and that current treatment guidelines support retreatment of re-infected PWID.

The Impact of an Online Training Program About Cancer Clinical Trials on Primary Care Physicians' Knowledge, Attitudes and Beliefs, and Behavior.

Participation in cancer clinical trials (CCTs) is critical to improving cancer treatments and quality of care. However, rates of patient participation remain low. Research has shown that a trusted physician recommendation is an important influence on patients' decisions to enroll in a CCT. Improving primary care providers' (PCPs') knowledge, attitudes, and beliefs about CCTs is a promising potential path for improving CCT participation. The aim of this pilot study was to test the effect of an online educational course for PCPs about clinical trials on primary care providers' knowledge, attitudes and beliefs, and behavior. Forty-one PCPs in the New York City area participated in a 1-h online training session on cancer clinical trials. These PCPs had self-selected to complete the training in a previous survey. The objectives of the training module were to (1) educate the PCPs about clinical trials, with a focus on overcoming misconceptions; and (2) discuss roles of PCPs in partnering with oncologists to help patients gain access to clinical trials. The training module included didactics, audio excerpts, and case descriptions. Participants completed a pre-test immediately before taking the course, a post-test immediately after taking the course, and a 3-month post-course survey. All three assessments included a general T/F knowledge test, a 7-item attitude/belief scale, and a knowledge test focused specifically on local resources and access for clinical trials. Forty-one PCPs completed the module and the pre-post course surveys. Eighty percent (33/41) also completed the 3-month post-course survey. General knowledge and local knowledge increased significantly (p < .05) from pre- to post-course. At 3 months post-training, both general and local knowledge scores remained significantly increased from baseline. For those who completed the 3-month post-course survey, attitudes and beliefs increased significantly from pre- to post-course, but this change was not sustained at 3 months post-training. At 3 months post-training, 52% of the PCPs who had an interaction with a recently diagnosed cancer patient reported speaking with patients about CCTs as a result of the training. A brief online course showed significant and sustained improvement in PCPs' general and local knowledge about cancer clinical trials, which translated into self-reported behavior change. Future dissemination of the course and further research into its impact are important next steps.

Acupuncture and heart rate variability: a systems level approach to understanding mechanism.

Recent research has elucidated several different mechanisms for acupuncture. However, the interrelationship between these mechanisms and how acupuncture affects complex physiological systems is still not understood. Heart rate Variability (HRV), the beat-to-beat fluctuations in the rhythm of the heart, results from the regulation of the heart by the autonomic nervous system (ANS). Low HRV is associated with increased risk of all-cause mortality and is a marker for a wide range of diseases. Coherent HRV patterns are associated with increased synchronization between the two branches of the ANS, and when sustained for long periods of time result in increased synchronization and entrainment between multiple body systems. There is strong evidence from randomized placebo controlled trials that acupuncture modulates HRV. This may represent a mechanistic pathway for global physiological regulation, which is congruent with East Asian medical theory. The ability of acupuncture to improve HRV could be used as a tool in acupuncture research and practice to monitor treatment effectiveness and the impact on quality of life.

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk.

BACKGROUND: An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described. METHODS: The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945-1964). The study was conducted at three primary care clinics in the Bronx, New York. RESULTS: Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P<0.001) and 9.9% during the birth cohort period (P<0.001). CONCLUSIONS: Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

Food insecurity and obesity in New York City primary care clinics.

BACKGROUND: Hunger continues to be a problem in New York City; paradoxically, the city also has disproportionally high rates of diabetes and obesity. Some research suggests that food insecurity leads to obesity. METHODS: We undertook a cross-sectional "card study" in which doctors working at 8 New York City area primary care practices administered a brief, anonymous survey to patients they saw during clinic sessions. The survey included a 2-question food insecurity screen and questions about enrollment in nutrition assistance programs. Height and weight were also measured at the visit. RESULTS: Cards were completed for 558 patients (65.1% female; 74.7% adults; 78.5% conducted in English). Fifty-five percent of patients were receiving some form of food assistance. More than half of patients (51.7%) reported some degree of food insecurity. Of adult participants, 21.8% had normal weight, 29.1% were overweight, and 48.2% were obese. Food insecurity was significantly associated with increasing body mass index in women not receiving food assistance. There was no significant association between body mass index and food insecurity in children. DISCUSSION: In an urban population, overweight and obesity are very common as is food insecurity. We found an association between food insecurity and obesity only among women not receiving food assistance suggesting a possible protective role for food assistance. Providers should consider food insecurity in similar populations when trying to address obesity.

Vaginal hygiene and douching: perspectives of Hispanic men.

Vaginal douching is widely practised by women in the USA, particularly among minority ethnic groups, and is associated with increased risk of pelvic and vaginal infections. Douching practices are shaped by social and cultural norms regarding female hygiene, reproduction and sexuality. Little previous research has addressed the beliefs and practices of Latina women and none has included the perspective of men, though limited data suggests that women may douche to please male partners. The present study seeks to identify the socially and culturally shaped beliefs and attitudes that influence douching practices from the perspective of Latino men. We conducted in-depth qualitative interviews in English or Spanish with adult Latino men seeking primary care at a community health centre in New York City. Results indicate that these Latino men (mostly of Caribbean descent) are emphatic about the role of cleanliness in vaginal health, reporting that it substantially influences their choice of partner. Most are very supportive of douching, which they consider a necessary hygiene activity. Vaginal health is perceived as a state that must be attained and maintained through proactive hygiene measures that remove seminal residue, menstrual blood, sweat and bacteria that contaminate the vagina. The implications of these findings for interventions with Latina women are discussed.

An investigation of douching practices in the botánicas of the Bronx.

Douching is a common practice in women and has been associated with adverse health outcomes. In order to explore douching products and practices we conducted qualitative interviews in ten botánicas (stores that provide healing and spiritual services to immigrant communities) located in New York City. We interviewed 15 people, 14 of whom were botánica owners and employees and ten of whom were women. We found that douching was not easily separated from the more holistic concerns of botánica customers involving health, well-being and spirituality. These issues included abortion, infertility, menopause, the prevention and treatment of infections, sexuality, cleanliness, hygiene and relationship issues. The vagina was seen as a sensitive, even vulnerable part of the body, not clearly distinguished from other female organs. A variety of products were used in the vagina in the form of creams, douches, suppositories, baths and herbal steaming of the urogenital area. Alum, an astringent, was used for the purposes of vaginal tightening to enhance sexual pleasure for the partner, to make the vagina 'younger', or to hide evidence of infidelity. Botánicas are part of a complex healing system with conceptual models different from those of allopathic medicine. These models may not be unique to the botánicas.

Primary care for urban adolescent girls from ethnically diverse populations: foregone care and access to confidential care.

Adolescent girls face unique challenges in health care utilization, which can result in unmet needs. We sought to describe settings of usual care and primary care use, and to identify predictors of foregone care and experience of confidential care in a primarily racial/ethnic minority low-income sample. We conducted an anonymous computer-assisted self-administered survey of 9th-12th grade girls (n=819) in three Bronx public high schools, the majority of whom were Hispanic (69.8%) and Black (21.4%). Most (80%) reported having a usual source of care. Of these, 77.2% had a regular doctor. Those least likely to have a usual source of care were non-U.S. born girls (73.1% vs. 83.1%) and less acculturated girls. Predictors of foregone care in the last year include being sexually active, poor family social support, and low self esteem. Predictors of access to confidential care at last visit were age, self-efficacy for confidential care, having a regular doctor, setting of care, and having had a recent physical exam. Many urban adolescent girls, especially non-U.S. born girls, lack a usual source of care and regular health care provider. Continued attention to reducing both financial and non-financial barriers to care is required to ensure access to and quality of care for diverse populations.

Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months.

OBJECTIVE: To determine whether an individualized, prenatal and postnatal, lactation consultant intervention resulted in increased cumulative intensity of breastfeeding up to 52 weeks. DESIGN: The randomized, nonblinded, controlled trial recruited women from prenatal care. Baseline prenatal interviews covered demographic data and breastfeeding experience, intention, and knowledge. Interviews at 1, 2, 3, 4, 6, 8, 10, and 12 months after birth collected data on weekly feeding patterns, infant illness, and infant health care use. SETTING: Two community health centers serving low-income, primarily Hispanic and/or black women. PARTICIPANTS: The analytic sample included 304 women (intervention: n = 145; control: n = 159) with > or = 1 postnatal interview. INTERVENTION: Study lactation consultants attempted 2 prenatal meetings, a postpartum hospital visit, and/or home visits and telephone calls. Control subjects received the standard of care. OUTCOME MEASURES: Cumulative breastfeeding intensity at 13 and 52 weeks, based on self-reports of weekly feeding, on a 7-level scale. RESULTS: The intervention group was more likely to breastfeed through week 20 (53.0% vs 39.3%). Exclusive breastfeeding rates were low and did not differ according to group. In multivariate analyses, control subjects had lower breastfeeding intensity at 13 weeks (odds ratio [OR]: 1.90; 95% confidence interval [CI]: 1.13-3.20) and 52 weeks (OR: 2.50; 95% CI: 1.48-4.21). US-born control subjects had lowest breastfeeding intensity at 13 weeks (OR: 5.22; 95% CI: 2.43-11.22) and 52 weeks (OR: 5.25; 95% CI: 2.44-11.29). There were no significant differences in breastfeeding intensity among the US-born intervention, foreign-born intervention, and foreign-born control groups. CONCLUSIONS: This "best-practices" intervention was effective in increasing breastfeeding duration and intensity. Breastfeeding promotion should focus on US-born women and exclusive breastfeeding.

Breast-feeding promotion interventions: good public health and economic sense.

The health benefits of breast-feeding are well documented, as are the positive effects of breast-feeding promotion interventions. There is a clear dose-response relationship between breast-feeding and infant health in the first year of life, and beyond. Further, nearly all breast-feeding promotion interventions improve--at least minimally--breast-feeding initiation and duration rates. However, the extent to which the costs of such interventions might be offset by the potential health care cost savings during the infant's first year of life has not been examined. From a health policy perspective, such an economic analysis is indicated.