Using mobile clinics to deliver HIV testing and other basic health services in rural Malawi.

CONTEXT: The majority of Malawians are impoverished and primarily dependant on subsistence farming, with 85% of the population living in a rural area. The country is highly affected by HIV and under-resourced rural health centers struggle to meet the government's goal of expanding HIV testing, antiretroviral treatment, and other basic services. ISSUE: This report describes the work of two four-wheel drive mobile clinics launched in 2008 to fill an identified service gap in the remote areas of Mulanje District, Malawi. The program was developed by an international non-governmental organization, Global AIDS Interfaith Alliance (GAIA), and the Mulanje District Health Office, with funding from the Elizabeth Taylor HIV/AIDS Foundation. The clinics provide: (1) rapid HIV testing and treatment referral; (2) diagnosis and treatment of malaria; (3) sputum collection for TB screening; (4) diagnosis and treatment of sexually transmitted and opportunistic infections; and (5) pre-natal care. The clinic vehicles provide medical supplies and personnel (a clinical officer, nurse, and nurse aide) to set up clinics in community buildings such as churches or schools. LESSONS LEARNED: In such a project, the implementation process and schedule can be affected by medication, supply chain and infrastructural issues, as well as governmental and non-governmental requirements. Timelines should be sufficiently flexible to accommodate unexpected delays. Once established, service scheduling should be flexible and responsive; for instance, malaria treatment rather than HIV testing was most urgently needed in the season when these services were launched. Assessing the impact of healthcare delivery in Malawi is challenging. Although mobile clinic and the government Health Management Information System (HMIS) data were matched, inconsistent variables and gaps in data made direct comparisons difficult. Data collection was compromised by the competing demand of high patient volume; however, rather than reducing the burden on existing health centers, the data suggest that the mobile clinics provided services for people who otherwise may not have attended a health center. The GAIA mobile clinics were integrated into a catchment area through a community participation model, allowing point-of-care primary health services to be provided to thousands of people in remote rural villagers. Strong relationships have been forged with local community leaders and with Malawi Ministry of Health officers as the foundation for long-term sustainable engagement and eventual integration of services into Health Ministry programs.

Application of Leventhal's self-regulation model to Chinese immigrants with type 2 diabetes.

PURPOSE AND BACKGROUND: To demonstrate the application of Leventhal's Self-Regulation Model with a group of Chinese immigrants with type 2 diabetes. DESIGN AND METHODS: Using qualitative methods and a convenience sample of 30 Chinese immigrants, interviews were analyzed by categorizing data according to the components of the Leventhal model. Participants were recruited from a U.S. West Coast Chinatown health center and were interviewed to identify beliefs about health and illness that are shaped by cultural factors. FINDINGS: Application of the self-regulation model indicated that participants were unclear about the etiology and chronicity of diabetes and interpreted the illness as stigmatizing. Coping strategies included wishful thinking, belief in powerful others, keeping diabetes a secret, and avoiding social situations. Participants lacked the ability to appraise the effects of their coping strategies. CONCLUSIONS: Health care providers can help people with type 2 diabetes develop critical-thinking strategies instead of relying on sets of rules to gain control of blood glucose levels. The self-regulation model was useful in profiling a vulnerable group whose diabetes management, social environment, and self-image could be improved through thoughtful patient education strategies.

Activities of the APN to enhance unpartnered elders self-efficacy after myocardial infarction.

Unpartnered elders recovering from a myocardial infarction find themselves with limited support to contend with their physical and emotional recovery. The advanced practice nurse (APN) can play an instrumental role in improving the health outcomes of these elders. Detailed description of the activities of the APN that affect patient outcomes in current randomized clinical trials have been inadequate in published reports. Therefore, the purpose of this article is to describe the activities of an APN in a nurse-coached intervention study for unpartnered elders post-myocardial infarction. Thematic analysis from the subject logs and narratives from the APN identified the four themes of patient education, validation/feedback, encouragement/support, and problem solving as the unique activities of the APN. These activities enhanced the recovery of these vulnerable unpartnered elders after a myocardial infarction.

The peer advisor experience providing social support.

Research shows a link between increased social support and decreased complications after myocardial infarction (MI). In a current randomized controlled trial (RCT), a social support intervention administered by nurse and peer advisors is being examined to determine its influence on the health outcomes of unpartnered, post-MI elders. This qualitative study (as part of the larger RCT) sought a better understanding regarding the experience of the peer advisor. Data sources included peer advisor logs, a focus group, and telephone interviews with peer advisors. Findings revealed that helping, mutual sharing, committing, and benefiting are characteristics of peer experiences. Primarily because of their personal experience of recovery from MI, peer advisors had a remarkable ability to relate to assigned post-MI elders, offering a unique form of social support complementary to current health practices.

Life-span development: a review of theory and practice for families with chronically ill members.

While the family's primacy in the patient's adaptation to chronic illness increasingly is being recognized by health professionals and social scientists, the reverse side of the coin, that is, the impact of chronicity on the family, has received little attention. A life-span development perspective is used to enrich the more traditional frameworks employed to study family development and also as a unifying framework from which to view the impact of illness on individual family members and the family as a unit. A review of selected literature reveals a profile of families most at risk for serious disruption in situations involving chronic illness. Propositions suggesting interventions directed at patients and families experiencing chronicity are derived.

Life-span development: refreshing a theoretical and practice perspective.

Although the life-span development framework has been utilized by social scientists since the 1970s, the discipline of nursing is overdue in recognition and use of this theoretical and methodological framework. The framework's unique focus on biological (normative age-graded), sociohistorical (normative history-graded), and non-normative influences (events occurring out of synchrony) provides a constructive approach to research with both individuals and families.

Meeting the needs of unpartnered elders: a peer training program involving elders with myocardial infarction.

Myocardia infarction (MI) is the leading cause of death in elderly adults. For those elderly who do recover, results are less than optimal when compared to those seen with younger patients. With a shortened length of stay in hospitals for elderly MI patients, and an increase in life expectancy that leads to an estimated 33 million elders in the U.S. population, there is a growing community-based population of elders who are recovering from MI. The use of elders as peer advisors has been demonstrated to be a cost-effective method of promoting health and enhancing recovery, with only a modest investment of the professional healthcare provider's time and money. An innovative, low-cost intervention matches recent MI elders who are unpartnered--and at higher risk for morbidity and mortality than partnered elders--to a peer advisor who has also survived acute MI in the past.

Quality of life and social environment as reported by Chinese immigrants with non-insulin-dependent diabetes mellitus.

Non-insulin-dependent diabetes mellitus (NIDDM) has been associated with stressful events such as immigration. The purpose of this paper is to report a pilot study that tested translated and back-translated instruments to ascertain factors related to diabetes management in a group of Chinese immigrants with diabetes. The descriptive, cross-sectional design included a convenience sample of 30 Chinese immigrants who had been diagnosed with NIDDM for at least 1 year. Consenting participants completed paper- and-pencil questionnaires (Diabetes Family-Behavior Checklist II, Diabetes Quality of Life, and MDRTC Knowledge Test) that had been translated and back-translated into Chinese and returned them in stamped, self-addressed envelopes. Results indicated that most of the scale and subscale reliabilities were similar to those published previously. Study participants had received limited diabetes education, reported many problems managing diabetes, especially in terms of social and vocational issues, and reported dissatisfaction with their quality of life. Diabetes-related family supportive behaviors were rated positively indicating the importance of including family members in educational programs.

Women and heart attacks: prevention, diagnosis, and care.

Despite being viewed as a male health problem, more women die from heart disease than men. The literature and preliminary research data reviewed clearly support that gender differences exist. The higher prevalence of myocardial infarction in older women and those with other known risk factors suggests the etiology, pathophysiology, and treatment is the same as for men. Differences in socioeconomic status, psychosocial profiles, presenting symptoms, disease progression, and a poorer response to treatment suggests that myocardial infarction in women is not fully understood. Women need to know they are at risk and not delay seeking treatment for subtle but important symptoms. Assessment strategies that take into account the woman's body, personal profile, and the female pattern of variant angina, non-Q wave, nonocclusive infarction are reviewed. Considering the literature that links social support with survival, mobilizing support to help the women direct energies to her own recovery becomes a necessary intervention. Implications to health teaching, diagnostic testing, diagnosis, referral, and the effective management of women with myocardial infarction are delineated.

Reliability and validity data for a Chinese translation of the Center for Epidemiological Studies-Depression.

A translated version of the CES-Depression scale attained a reliability coefficient alpha of 0.92 in a group of 30 adult Chinese persons with noninsulin-dependent diabetes mellitus. Fifteen percent of the sample scored 16 or above, which has been noted as indicative of depression in U.S. samples. The validity of the instrument was assessed through an in-depth content analysis and through convergent validity analyses. Comparison of depression scores of this sample with those from English-speaking Occidentals shows that diabetes disease-related factors may be an important influence on depression.

Revisiting nurse knowledge about diabetes: an update and implications for practice.

This study attempted to ascertain the diabetes knowledge level of nurses in a university medical center, to describe correlates of nurse knowledge, and to compare levels of diabetes knowledge between nursing units. A convenience sample of staff nurses (n = 99) from six inpatient units and an ambulatory care center volunteered to complete a previously developed, 45-item questionnaire testing their knowledge of basic concepts about diabetes mellitus. Analysis of variance, comparing the nursing units, indicated a significant difference between units (P = .04) on the knowledge questionnaire. In a 4-step, hierarchical, multiple regression analysis, variables related to how competent the nurses felt in caring for diabetic patients and the number of diabetic patients cared for in the past month explained 28% of the variance in diabetes knowledge. Although this study corroborates earlier findings, questions still remain concerning the general adequacy of nurses' knowledge about diabetes.

Psychosocial adjustments of coronary artery disease patients and their spouses: nursing implications.

Nurses caring for the patient with CAD are most effective when they recognize that many factors affect psychosocial adjustment to heart disease, with age and gender as two prominent influences. Likewise, spouses of patients with CAD require special attention and assessment so that their caregiving and recovery from a cardiac-related event is successful. Caregiving spouses have been found to have more mood disturbance, less satisfaction with marriage and family, and lower levels of social support than patients, suggesting that attention to their concerns is paramount.

Differences in recovery from cardiac surgery: a profile of male and female patients.

The specific aim of this study is to compare and contrast the biophysical and psychosocial profile of men and women undergoing cardiac surgery (coronary artery bypass graft and valve replacement) during the perioperative and home recovery period. Coronary artery disease appears to be qualitatively worse in women than men although the prevalence in women does not approach that in men until the seventh decade. Valvular disorders also reveal a different profile by sex with the greater valvular problems in women related to the fact that women have more rheumatic heart disease. A prospective, longitudinal design with a convenience sample of 117 patients undergoing cardiac surgery and their spouses (234 subjects) from five Northern California hospitals was used to tap patient response at three critical perioperative data points. Female patients were observed during the perioperative period to have significantly more shortness of breath, poorer cardiac functional status (New York Heart Association), significantly longer intensive care unit stays, and proportionately more deaths. At 1 and 3 months after discharge, however, their recoveries did not differ significantly from men's when they were compared on sexuality, recreation, or return-to-work variables. Surprisingly, female patients had significantly less mood disturbances as measured by the Profile of Mood States than their male counterparts, and they scored higher on measures of family satisfaction than did male patients. Implications of the study involve early recognition of heart disease in women, preparation of families for longer intensive care unit stays, and appreciation of different psychosocial responses to surgery.

Life-span development: a review of theory and practice for families with chronically ill members.

While the family's primacy in the patient's adaptation to chronic illness increasingly is being recognized by health professionals and social scientists, the reverse side of the coin, that is, the impact of chronicity on the family, has received little attention. A life-span development perspective is used to enrich the more traditional frameworks employed to study family development and also as a unifying framework from which to view the impact of illness on individual family members and the family as a unit. A review of selected literature reveals a profile of families most at risk for serious disruption in situations involving chronic illness. Propositions suggesting interventions directed at patients and families experiencing chronicity are derived.