Learning From Our Strengths: Exploring Strategies to Support Heart Health in Indigenous Communities.

Indigenous populations have remained resilient in maintaining their unique culture and values, despite facing centuries of colonial oppression. With many discriminatory policies continuing to disempower Indigenous peoples, First Nations communities have been reported to experience a higher level of cardiovascular disease (CVD)-related mortality, compared to that in the general population. Many of the risk factors contributing to the burden of CVD have been attributed to the impact of colonization and the ongoing dismissal of Indigenous knowledge. Despite Indigenous peoples recognizing the value of addressing their mental, physical, spiritual, and emotional well-being in balanced totality, current health services focus predominantly on the promotion of Western biomedicine. To begin to move toward reconciliation, a better understanding of how Indigenous health is defined within different cultural worldviews is needed. The objective of this scoping review was to explore the various Western and/or Indigenous strategies used for the prevention of CVD and the management of heart health and wellness in Indigenous communities in Canada. In this review, a total of 3316 articles were identified, and only 21 articles met the eligibility criteria. Three major themes emerged, as follows: (i) valuing of the emotional domain of health through cultural safety; (ii) community is at the core of empowering health outcomes; and (iii) bridging of cultures through partnership and mutual learning. Most studies recognized the importance of community engagement to develop heart health strategies that integrate traditional languages and cultures. However, to move toward the delivery of culturally safe care, health systems need to rebuild their relationship with Indigenous peoples.

Les populations autochtones ont toujours fait preuve de résilience dans le maintien de leurs cultures et de leurs valeurs uniques, malgré des siècles d'oppression coloniale. En raison des nombreuses politiques discriminatoires qui continuent de priver les peuples autochtones de certains pouvoirs, on rapporte que les communautés des Premières Nations ont un taux de mortalité liée aux maladies cardiovasculaires (MCV) supérieur à celui observé dans la population générale. De nombreux facteurs de risque qui contribuent au fardeau des MCV ont été attribués aux répercussions de la colonisation et au rejet continu du savoir autochtone. Malgré le fait que les peuples autochtones reconnaissent l'avantage de prendre soin de leur bien-être mental, physique, spirituel et émotionnel dans une intégralité équilibrée, les services de santé actuels sont essentiellement axés sur la promotion de la biomédecine occidentale. Afin de commencer à nous diriger vers la réconciliation, nous devons mieux comprendre la façon dont les peuples autochtones définissent la santé au sein de différentes visions culturelles du monde. L'objectif de cette étude de portée était d'explorer les diverses stratégies occidentales ou autochtones de prévention des MCV et de prise en charge de la santé et du bien-être cardiaques chez les communautés autochtones du Canada. Dans le cadre de cette étude, 3 316 articles ont été recensés, et seulement 21 d'entre eux répondaient aux critères de sélection. Trois principaux thèmes ont été dégagés, soit : (i) la sécurité culturelle permet de mettre en avant l'importance du domaine émotionnel de la santé; (ii) la communauté est au centre de l'autonomie en matière de devenir de la santé; et (iii) le lien entre les cultures doit se faire au moyen de partenariats et d'apprentissages mutuels. La plupart des études reconnaissaient l'importance de l'engagement communautaire pour mettre au point des stratégies relatives à la santé du cœur qui intègrent les langues et les cultures traditionnelles. Toutefois, afin de passer à la prestation de soins respectueux des cultures, les systèmes de santé doivent reconstruire leur relation avec les peuples autochtones.

Exploring the use of a digital therapeutic intervention to support the pediatric cardiac care journey: Qualitative study on clinician perspectives.

Pediatric heart disease currently effects over one million infants, children, and adolescents in the United States alone. Unlike the adult population, pediatric patients face a more uncertain path with factors relating to their growth and maturation creating levels of complexity to their care management. With mobile phones increasingly being utilized amongst adolescents, digital therapeutics tools could provide a platform to help patients and families manage their condition. This study explored clinicians' views on the use of a digital therapeutic program to support pediatric heart disease management. Using the principles from user-centered design, semi-structured interviews were conducted with 4 cardiologists, 3 nurse practitioners and 1 cardiology fellow at the Hospital for Sick Children. All interview transcripts underwent inductive thematic analysis using Braun and Clarke's iterative six-phase approach. To further contextualize the analytic interpretation of the study findings, Eakin and Gladstone's value-adding approach was used. Five themes were identified: (i) multidisciplinary model of care; (ii) patient care needs change over time; (iii) treatment burden and difficulties in care management; (iv) transition to adulthood; and (v) filling care gaps with digital health. Clinicians valued the opportunity to monitor a patient's health status in real-time, as it allowed them to modify care regimens on a more preventive basis. However, with adolescent care often varying according to the patient's age and disease severity, a digital therapeutic program would only be valuable if it was customizable to the patients changing care journey. Digital therapeutic programs can ease the process of self-care for adolescents with heart disease throughout the growth and maturation of their care journey. However, to ensure the sustained use of a program, there is a need to work collaboratively with patients, caregivers, and clinicians to ensure their lived experiences guide the design and delivery of the overall program.

Heart Health Begins With Community: Community-Based Research Exploring Innovative Strategies to Support First Nations Heart Health.

Background: Indigenous people have displayed their strength through their holistic practices and spiritual connection to the land. Despite overcoming the impact of discriminatory and disempowering policies within Western institutions, Indigenous people continue to experience a higher risk of cardiovascular disease, compared to the general population. To move toward improving Indigenous health outcomes, researchers need to work in partnership with communities to develop heart health strategies centred on their experienced barriers and sources of healing. We conducted a community-based explorative study in Moosonee, Ontario to explore the local community's needs and priorities regarding heart health and wellness. Methods: A convenience sample of community members and healthcare professionals were invited to participate in a sharing circle. Qualitative data were analyzed using conventional content analysis and the Indigenous method of two-eyed seeing. Results: Eight community members and 5 healthcare professionals participated in the sharing circle. Four dominant themes were identified: (1) heart health is more than metrics; (2) honouring our traumas; (3) destigmatizing care through relationship building; and (4) innovative solutions start with community. With the history of mistreatment among Indigenous people, strength-based solutions involved rebuilding clinical relationships. To bring care closer to home, digital health tools were widely accepted, but the design of these tools needs to integrate both Western and Indigenous approaches to healing. Conclusions: Indigenous health upholds the physical, emotional, psychological, and spiritual needs of an individual as being of equal importance. To improve community heart health, strategies should start by strengthening broken bonds and bridging multiple worldviews of healing.

Contexte: Les peuples autochtones tirent une grande force de leurs pratiques holistiques et de leur lien spirituel avec le territoire, et même s'ils ont surmonté les répercussions des politiques discriminatoires et marginalisantes des institutions occidentales, ils présentent encore un risque de maladies cardiovasculaires supérieur à celui de la population générale. Afin d'aider à améliorer la santé cardiovasculaire des Autochtones, les chercheurs doivent travailler avec les communautés pour mettre en place des stratégies qui tiennent compte des obstacles en matière de soins de santé et des méthodes de guérison traditionnelles. Nous avons réalisé une étude exploratoire en milieu communautaire à Moosonee (Ontario) dans le but d'explorer les besoins et les priorités de la communauté locale en matière de santé cardiovasculaire et de bien-être. Méthodologie: Des membres de la communauté et des professionnels de la santé ont été invités à participer à un cercle de partage. Les données qualitatives ont été analysées au moyen d'une analyse classique et de la méthode autochtone dite à double perspective. Résultats: Huit membres de la communauté et cinq professionnels de la santé ont participé au cercle de partage. Quatre principaux thèmes ont été abordés : 1) la santé cardiovasculaire va au-delà de ce qui se mesure; 2) il faut tenir compte des traumatismes; 3) il faut déstigmatiser les soins en nouant des relations et 4) les solutions novatrices doivent reposer sur la participation de la communauté. En raison du passé de maltraitance envers les peuples autochtones, les solutions axées sur les forces devaient permettre de restaurer la confiance envers les soins cliniques. Les outils de santé numérique, bien adaptés aux besoins de la communauté, ont été largement acceptés, mais ils doivent intégrer les méthodes de soins occidentales et autochtones. Conclusions: Selon la vision autochtone, la santé repose en parts égales sur les aspects physiques, émotionnels, psychologiques et spirituels d'une personne. L'amélioration de la santé cardiovasculaire des membres de la communauté passe donc avant tout par des stratégies qui permettent de recréer les liens qui ont été brisés et qui intèrent plusieurs visions thérapeutiques.

Bridging community and clinic through digital health: Community-based adaptation of a mobile phone-based heart failure program for remote communities in Uganda.

Background: In Uganda, limited healthcare access has created a significant burden for patients living with heart failure. With the increasing use of mobile phones, digital health tools could offer an accessible platform for individualized care support. In 2016, our multi-national team adapted a mobile phone-based program for heart failure self-care to the Ugandan context and found that patients using the system showed improvements in their symptoms and quality of life. With approximately 84% of Ugandans residing in rural communities, the Medly Uganda program can provide greater benefit for communities in rural areas with limited access to care. To support the implementation of this program within rural communities, this study worked in partnership with two remote clinics in Northern Uganda to identify the cultural and service level requirements for the program. Methods: Using the principles from community-based research and user-centered design, we conducted a mixed-methods study composed of 4 participatory consensus cycles, 60 semi-structured interviews (SSI) and 8 iterative co-design meetings at two remote cardiac clinics. Patient surveys were also completed during each SSI to collect data related to cell phone access, community support, and geographic barriers. Qualitative data was analyzed using inductive thematic analysis. The Indigenous method of two-eyed seeing was also embedded within the analysis to help promote local perspectives regarding community care. Results: Five themes were identified. The burden of travel was recognized as the largest barrier for care, as patients were travelling up to 19 km by motorbike for clinic visits. Despite mixed views on traditional medicine, patients often turned to healers due to the cost of medication and transport. With most patients owning a non-smartphone (n = 29), all participants valued the use of a digital tool to improve equitable access to care. However, to sustain program usage, integrating the role of village health teams (VHTs) to support in-community follow-ups and medication delivery was recognized as pivotal. Conclusion: The use of a mobile phone-based digital health program can help to reduce the barrier of geography, while empowering remote HF self-care. By leveraging the trusted role of VHTs within the delivery of the program, this will help enable more culturally informed care closer to home. Supplementary Information: The online version contains supplementary material available at 10.1186/s44247-023-00020-5.

A digital self-care intervention for Ugandan patients with heart failure and their clinicians: User-centred design and usability study.

Background: The prevalence of heart failure (HF) is increasing in Uganda. Ugandan patients with HF report receiving limited information about their illness and associated self-care behaviours. Interventions targeted at improving HF self-care have been shown to improve patient quality of life and reduce hospitalizations in high-income countries. However, such interventions remain underutilized in resource-limited settings like Uganda. This study aimed to develop a digital health intervention that enables improved self-care amongst HF patients in Uganda. Methods: We implemented a user-centred design (UCD) process to develop a self-care intervention entitled Medly Uganda. The ideation phase comprised a scoping review and preliminary data collection amongst HF patients and clinicians in Uganda. An iterative design process was then used to advance an initial prototype into a functional digital health intervention. The evaluation phase involved usability testing of the intervention amongst Ugandan patients with HF and their clinicians. Results: Medly Uganda is a digital health intervention that allows patients to report daily HF symptoms, receive tailored treatment advice and connect with a clinician when showing signs of decompensation. The system harnesses Unstructured Supplementary Service Data (USSD) technology that is already widely used in Uganda for mobile phone-based financial transactions. Usability testing showed Medly Uganda to be both acceptable and feasible amongst clinicians, patients and caregivers. Conclusions: Medly Uganda is a functional digital health intervention with demonstrated acceptability and feasibility in enabling Ugandan HF patients to better care for themselves. We are hopeful that the system will improve self-care efficacy amongst HF patients in Uganda.

Can the Healthcare System Improve Food Security? A Need for Collaborative Community Partnerships.

The COVID-19 pandemic has heightened the food insecurity crisis in Canada, and existing supports have been largely insufficient to meet the food needs of communities. In response to increasing reports of food insecurity among Toronto residents during the pandemic, the Food RX program was developed as a collaborative initiative between FoodShare Toronto - a local, community-based food justice organization - and the University Health Network, a large university-affiliated hospital network in downtown Toronto, ON. This commentary describes the Food RX program, highlights the lessons learned during its early implementation and offers a set of recommendations for building community partnerships moving forward.

The Resilience of Cardiac Care Through Virtualized Services During the COVID-19 Pandemic: Case Study of a Heart Function Clinic.

BACKGROUND: Virtual care has historically faced barriers to widespread adoption. However, the COVID-19 pandemic has necessitated the rapid adoption and expansion of virtual care technologies. Although the intense and prolonged nature of the COVID-19 pandemic has renewed people's interest in health systems resilience, which includes how services adapt or transform in response to shocks, evidence regarding the role of virtual care technologies in health systems resilience is scarce. OBJECTIVE: At Toronto General Hospital in Ontario, Canada, the rapid virtualization of cardiac care began on March 9, 2020, as a response to the pandemic. The objective of this study was to understand people's experiences with and the barriers and facilitators of the rapid virtualization and expansion of cardiac care resulting from the pandemic. METHODS: A single-case study was conducted with 3 embedded units of analysis. Patients, clinicians, and staff were recruited purposively from an existing mobile, phone-based telemonitoring program at a heart function clinic in Toronto, Canada. Individual, semistructured phone interviews were conducted by two researchers and transcribed verbatim. An inductive thematic analysis at the semantic level was used to analyze transcripts and develop themes. RESULTS: A total of 29 participants were interviewed, including patients (n=16), clinicians (n=9), and staff (n=4). The following five themes were identified: (1) patient safety as a catalyst for virtual care adoption; (2) piecemeal virtual care solutions; (3) confronting new roles and workloads; (4) missing pieces in virtual care; and (5) the inequity paradox. The motivation to protect patient safety and a piecemeal approach to virtual care adoption facilitated the absorptive and adaptive resilience of cardiac care during the COVID-19 pandemic. However, ad hoc changes to clinic roles and workflows, challenges in building relationships through remote methods, and widened inequities were barriers that threatened virtual care sustainment. CONCLUSIONS: We contend that sustaining virtual care hinges upon transformative actions (rather than adaptive actions) that strengthen health systems so that they can face the dynamic and emergent challenges associated with COVID-19 and other shocks. Based on the barriers and facilitators we identified, we present the lessons we learned and recommend transformations for sustaining virtual care during and beyond the COVID-19 pandemic.

Expanding Telemonitoring in a Virtual World: A Case Study of the Expansion of a Heart Failure Telemonitoring Program During the COVID-19 Pandemic.

BACKGROUND: To minimize the spread and risk of a COVID-19 outbreak, societal norms have been challenged with respect to how essential services are delivered. With pressures to reduce the number of in-person ambulatory visits, innovative models of telemonitoring have been used during the pandemic as a necessary alternative to support access to care for patients with chronic conditions. The pandemic has led health care organizations to consider the adoption of telemonitoring interventions for the first time, while others have seen existing programs rapidly expand. OBJECTIVE: At the Toronto General Hospital in Ontario, Canada, the rapid expansion of a telemonitoring program began on March 9, 2020, in response to COVID-19. The objective of this study was to understand the experiences related to the expanded role of a telemonitoring program under the changing conditions of the pandemic. METHODS: A single-case qualitative study was conducted with 3 embedded units of analysis. Semistructured interviews probed the experiences of patients, clinicians, and program staff from the Medly telemonitoring program at a heart function clinic in Toronto, Canada. Data were analyzed using inductive thematic analysis as well as Eakin and Gladstone's value-adding approach to enhance the analytic interpretation of the study findings. RESULTS: A total of 29 participants were interviewed, including patients (n=16), clinicians (n=9), and operational staff (n=4). Four themes were identified: (1) providing care continuity through telemonitoring; (2) adapting telemonitoring operations for a more virtual health care system; (3) confronting virtual workflow challenges; and (4) fostering a meaningful patient-provider relationship. Beyond supporting virtual visits, the program's ability to provide a more comprehensive picture of the patient's health was valued. However, issues relating to the lack of system integration and alert-driven interactions jeopardized the perceived sustainability of the program. CONCLUSIONS: With the reduction of in-person visits during the pandemic, virtual services such as telemonitoring have demonstrated significant value. Based on our study findings, we offer recommendations to proactively adapt and scale telemonitoring programs under the changing conditions of an increasingly virtual health care system. These include revisiting the scope and expectations of telemedicine interventions, streamlining virtual patient onboarding processes, and personalizing the collection of patient information to build a stronger virtual relationship and a more holistic assessment of patient well-being.

What do you mean by engagement? - evaluating the use of community engagement in the design and implementation of chronic disease-based interventions for Indigenous populations - scoping review.

BACKGROUND: Indigenous populations have remained strong and resilient in maintaining their unique culture and values, despite centuries of colonial oppression. Unfortunately, a consequential result of facing years of adversity has led Indigenous populations to experience a disproportionate level of poorer health outcomes compared to non-Indigenous populations. Specifically, the rate of Indigenous chronic disease prevalence has significantly increased in the last decade. Many of the unique issues Indigenous populations experience are deeply rooted in their colonial history and the intergenerational traumas that has subsequently impacted their physical, mental, emotional and spiritual well-being. With this, to better improve Indigenous health outcomes, understanding the local context of their challenges is key. Studies have begun to use modes of community engagement to initiate Indigenous partnerships and design chronic disease-based interventions. However, with the lack of a methodological guideline regarding the appropriate level of community engagement to be used, there is concern that many interventions will continue to fall short in meeting community needs. OBJECTIVE: The objective of this study was to investigate the how various community engagement strategies have been used to design and/or implement interventions for Indigenous populations with chronic disease. METHODS: A scoping review guided by the methods outlined by Arksey and O'Malley was conducted. A comprehensive search was completed by two reviewers in five electronic databases using keywords related to community engagement, Indigenous health and chronic disease. Studies were reviewed using a descriptive-analytical narrative method and data was categorized into thematic groups reflective of the main findings. RESULTS: We identified 23 articles that met the criteria for this scoping review. The majority of the studies included the use a participatory research model and the procurement of study approval. However, despite the claimed use of participatory research methods, only 6 studies had involved community members to identify the area of priority and only five had utilized Indigenous interview styles to promote meaningful feedback. Adapting for the local cultural context and the inclusion of community outreach were identified as the key themes from this review. CONCLUSION: Many studies have begun to adopt community engagement strategies to better meet the needs of Indigenous Peoples. With the lack of a clear guideline to approach Indigenous-based participatory research, we recommend that researchers focus on 1) building partnerships, 2) obtaining study approval and 3) adapting interventions to the local context.

Using an Electronic App to Promote Home-Based Self-Care in Older Patients With Heart Failure: Qualitative Study on Patient and Informal Caregiver Challenges.

BACKGROUND: Heart failure (HF) affects many older individuals in North America, with recurrent hospitalizations despite postdischarge strategies to prevent readmission. Proper HF self-care can potentially lead to better clinical outcomes, yet many older patients find self-care challenging. Mobile health (mHealth) apps can provide support to patients with respect to HF self-care. However, many mHealth apps are not designed to consider potential patient barriers, such as literacy, numeracy, and cognitive impairment, leading to challenges for older patients. We previously demonstrated that a paper-based standardized diuretic decision support tool (SDDST) with daily weights and adjustment of diuretic dose led to improved self-care. OBJECTIVE: The aim of this study is to better understand the self-care challenges that older patients with HF and their informal care providers (CPs) face on a daily basis, leading to the conversion of the SDDST into a user-centered mHealth app. METHODS: We recruited 14 patients (male: 8/14, 57%) with a confirmed diagnosis of HF, aged ≥60 years, and 7 CPs from the HF clinic and the cardiology ward at the Hamilton General Hospital. Patients were categorized into 3 groups based on the self-care heart failure index: patients with adequate self-care, patients with inadequate self-care without a CP, or patients with inadequate self-care with a CP. We conducted semistructured interviews with patients and their CPs using persona-scenarios. Interviews were transcribed verbatim and analyzed for emerging themes using an inductive approach. RESULTS: Six themes were identified: usability of technology, communication, app customization, complexity of self-care, usefulness of HF-related information, and long-term use and cost. Many of the challenges patients and CPs reported involved their unfamiliarity with technology and the lack of incentive for its use. However, participants were supportive and more likely to actively use the HF app when informed of the intervention's inclusion of volunteer and nurse assistance. CONCLUSIONS: Patients with varying self-care adequacy levels were willing to use an mHealth app if it was simple in its functionality and user interface. To promote the adoption and usability of these tools, patients confirmed the need for researchers to engage with end users before developing an app. Findings from this study can be used to help inform the design of an mHealth app to ensure that it is adapted for the needs of older individuals with HF.

Correction: Using an Electronic App to Promote Home-Based Self-Care in Older Patients With Heart Failure: Qualitative Study on Patient and Informal Caregiver Challenges.

[This corrects the article DOI: 10.2196/15885.].

Evaluation of Heart Failure Apps to Promote Self-Care: Systematic App Search.

BACKGROUND: Heart failure (HF) is a chronic disease that affects over 1% of Canadians and at least 26 million people worldwide. With the continued rise in disease prevalence and an aging population, HF-related costs are expected to create a significant economic burden. Many mobile health (mHealth) apps have been developed to help support patients' self-care in the home setting, but it is unclear if they are suited to the needs or capabilities of older adults. OBJECTIVE: This study aimed to identify HF apps and evaluate whether they met the criteria for optimal HF self-care. METHODS: We conducted a systematic search of all apps available exclusively for HF self-care across Google Play and the App Store. We then evaluated the apps according to a list of 25 major functions pivotal to promoting HF self-care for older adults. RESULTS: A total of 74 apps for HF self-care were identified, but only 21 apps were listed as being both HF and self-care specific. None of the apps had all 25 of the listed features for an adequate HF self-care app, and only 41% (31/74) apps had the key weight management feature present. HF Storylines received the highest functionality score (18/25, 72%). CONCLUSIONS: Our findings suggest that currently available apps are not adequate for use by older adults with HF. This highlights the need for mHealth apps to refine their development process so that user needs and capabilities are identified during the design stage to ensure the usability of the app.

Investigating the Use of Mobile Health Interventions in Vulnerable Populations for Cardiovascular Disease Management: Scoping Review.

BACKGROUND: Cardiovascular disease (CVD) has grown to become one of the leading causes of mortality worldwide. The advancements of CVD-related treatments have led to a decline in CVD prevalence among individuals in high-income countries (HICs). However, these improvements do not reflect the state of individuals in low- and middle-income countries (LMICs) and vulnerable subgroup populations in HICs, such as the Indigenous. To help minimize the health disparities in these populations, technology-based interventions have been offered as a potential solution, but there is concern regarding if they will be effective, or even needed, as these tools have been designed for use in HICs. OBJECTIVE: The objective of this study was to explore how mobile health (mHealth) interventions currently assist individuals in Indigenous communities and LMICs with CVD management. METHODS: A scoping review guided by the methods outlined by Arksey and O'Malley was conducted. A comprehensive search was completed by 2 reviewers in 5 electronic databases using keywords related to mobile health, cardiovascular disease, self-care, Indigenous communities, and LMICs. Studies were screened over 2 rounds and critically reviewed using a descriptive-analytical narrative method. Descriptive data were categorized into thematic groups reflecting the major findings related to the study objective. RESULTS: We identified a total of 11 original articles and 11 review papers that met the criteria for this scoping review. The majority of the studies included a telemonitoring- and text messaging (short message service, SMS)-related feature associated with the intervention. The use of SMS was the most common approach to effectively promote disease management among individuals in both LMICs and Indigenous communities. However, customizing for cultural considerations within the design of the intervention was highlighted as a pivotal component to encourage CVD management. Specifically, individuals emphasized that the inclusion of collaborative partnerships with community members would strengthen the effectiveness of the intervention by ensuring it was designed with the appropriate context. CONCLUSIONS: Technology-based interventions used within Indigenous communities and LMICs have shown their potential to assist individuals with managing their condition. Although the literature available regarding this topic is limited, this review outlines key components to promote the effective use of these tools in the context of these vulnerable populations.

Anti-diuretic activity of a CAPA neuropeptide can compromise Drosophila chill tolerance.

For insects, chilling injuries that occur in the absence of freezing are often related to a systemic loss of ion and water balance that leads to extracellular hyperkalemia, cell depolarization and the triggering of apoptotic signalling cascades. The ability of insect ionoregulatory organs (e.g. the Malpighian tubules) to maintain ion balance in the cold has been linked to improved chill tolerance, and many neuroendocrine factors are known to influence ion transport rates of these organs. Injection of micromolar doses of CAPA (an insect neuropeptide) have been previously demonstrated to improve Drosophila cold tolerance, but the mechanisms through which it impacts chill tolerance are unclear, and low doses of CAPA have been previously demonstrated to cause anti-diuresis in insects, including dipterans. Here, we provide evidence that low (femtomolar) and high (micromolar) doses of CAPA impair and improve chill tolerance, respectively, via two different effects on Malpighian tubule ion and water transport. While low doses of CAPA are anti-diuretic, reduce tubule K+ clearance rates and reduce chill tolerance, high doses facilitate K+ clearance from the haemolymph and increase chill tolerance. By quantifying CAPA peptide levels in the central nervous system, we estimated the maximum achievable hormonal titres of CAPA and found further evidence that CAPA may function as an anti-diuretic hormone in Drosophila melanogaster We provide the first evidence of a neuropeptide that can negatively affect cold tolerance in an insect and further evidence of CAPA functioning as an anti-diuretic peptide in this ubiquitous insect model.

A systematic review of interventions to improve medication information for low health literate populations.

BACKGROUND: Health literacy is a barrier to accurately understanding medication information. Current medication information is too difficult to understand for low health literate populations, which imposes a higher risk of misinterpreting prescription label instructions, dosage, duration, frequency, warning labels, written information and verbal pharmacist counseling. OBJECTIVES: The primary objective of this paper was to systematically review the evidence on interventions for improving medication knowledge and adherence for low health literate populations. METHODS: A database search of PubMed, Embase, International Pharmaceutical Abstracts, Web of Science, Cochrane Library, CINAHL, PsycINFO, and Scopus databases from the start of each database to studies published prior to March 30, 2015. Studies were included if they explicitly stated they included low health literate populations, included outcome measures for knowledge and/or adherence, focused on medication information, were written in English and were available in full text. Full text papers were excluded if there was no clear mention of an intervention being studied, if the intervention had no focus on any of the domains of health literacy, and if the authors did not specify the inclusion of patients with low health literacy. RESULTS: The review identified 1553 titles, 1009 abstracts, and 168 full text articles and included 47 articles in the final review. Of the 47 included studies, 70.2% (33/47) were published in the United States and 87.2 (41/47) were published between 2005 and 2014. Studies were grouped into six different types of interventions 1) written information 2) visual information 3) verbal information 4) label/medication bottle 5) reminder systems and 6) educational programs and services. Results demonstrate significant improvement of knowledge in 27 of 37 interventions and a significant improvement of adherence in 19 of 26 interventions. CONCLUSIONS: Interventions designed to support low health literate populations can improve patients' medication knowledge and adherence. The most effective interventions include additional aids that enforce written information, information that is personalized, information that is easy to navigate and tools that can be accessed when needed.