Overcoming the perceived barriers to health care access among single mothers in coastal Kenya.

OBJECTIVES: This study assesses the effects of a comprehensive empowerment intervention on barriers to health care access for single mothers in coastal Kenya. METHODS: We surveyed 41 single mothers who completed a pilot empowerment program and 60 single mothers who had not yet initiated the program. Comparisons were made using bivariate tests of association and logistic regression. RESULTS: Women in the pilot program were less likely to report transportation costs (OR = 0.26; 95 % CI [0.11-0.59], p = 0.001) and hospital fees (OR = 0.22 [0.10-0.49], p < 0.001) as barriers. Pilot program mothers were more likely to visit a public hospital for their children (OR = 4.38; [1.58-12.1], p = 0.004) and self (OR = 4.70; [1.54-14.4], p = 0.007) when ill. CONCLUSIONS: Empowerment programs can alleviate perceived barriers to health care among vulnerable populations.

Adherence practices among people living with HIV.

This paper offers a critique of patient-deficit models of adherence by examining the articulation of dosing schedules and food prohibitions with the structure of everyday lives. Interviews with 31 men and 4 women taking HAART show that doses associated with regular daily life events are most consistently taken, but many individuals rework official dosing guidelines around timing and food consumption. Barriers to adherence often arise from conflicting demands imposed by work schedules, different medications, food prohibitions, and even outright discrimination as in the case of US immigration policy. Adherence may be the outcome of compromises made in an effort to solve contradictory demands, and may be situational and related to the qualities of particular drugs, as much as to personality traits. Autobiographical narratives that give order to one's sense of self provide foundations upon which adherence decision making occurs. Finally, perceptions of drug effectiveness may lead to self-reinforcing adherence practices.

Standard quantitative assays for apoptosis.

The term apoptosis refers to a peculiar morphology of cell death. It is of special interest because it can be triggered physiologically (and pathologically), and it is regulated by the actions of specific gene products. Therefore, it can in principle be activated and suppressed by medical intervention. It thus is often important to determine whether cells are dying by apoptosis (or its less regulated counterpart, necrosis) and also to quantity the effect in a population of cells. Here the classic methods of apoptosis quantitation are described; they will be of particular use to those whose laboratories are set up for standard microscopical and biochemical techniques, who do apoptosis assays infrequently but wish them to be widely accepted and reproducible. A simple microscopic observation, using blue light illumination and a pair of fluorescent dyes, is recommended for most applications.

Trust us to make a difference: ensuring public confidence in the integrity of clinical research.

Investigator's and institutions' financial conflicts of interest in clinical research raise serious questions about the objectivity of such research, the safety of human subjects, and the threat to public trust in the integrity of clinical research. Yet the author makes clear that a conflict of interest is a state of affairs, not a behavior, and therefore not automatically a manifestation of improper actions. Indeed, conflicts of interest are quite common in complex settings such as those of academic medicine, and usually pose no problem, both because of the safeguards already in place and the integrity of most researchers. But it is clear that both non-financial conflicts of interest (e.g., career advancement, peer recognition, garnering grants and publications) and financial ones are double-edged: they can motivate individuals to do their best work but also can compromise judgment and undermine objectivity. In particular, conflicts of interest involving money, especially money from external sources, warrant special, targeted safeguards. And whether or not such conflicts of interest have actually created significant problems, academic medicine risks great peril if its leaders fail to respond to the growing perception that such problems exist. To foster public trust, the public needs to be better educated about how, with proper safeguards, limited financial incentives in the conduct of clinical research can benefit everyone. In addition, safeguards against the downsides of such financial incentives must be visibly strengthened. The author offers eight suggestions for what academic medicine's leaders might do in this regard (comply with existing full-disclosure requirements; establish principles governing institutional conflicts of interest; etc.). He closes by reiterating that the pursuit of clinical research depends entirely on the ability and willingness of the research community to merit public trust.

Collaborative care: a new model for a new century.

From the imagined vantage point of the year 2020, the author recounts the problems and deficiencies of health care in the 1990s and describes how academic medicine's leaders successfully confronted them. A key part of their strategy was to work together to form a coordinated network of medical schools, teaching hospitals, and academically oriented health systems, along with their staffs and a variety of community-based partners. In this way, they set a national agenda, pursued common goals, freely shared information and best practices, and cooperated to optimize their effectiveness in education, research, and clinical care. A major outcome of this new network was the Collaborative Care model of health care, based on the premise that a basic purpose of the health care system is to achieve measurable improvements in the health of individuals and communities in ways that are cost-conscious, quality-driven, evidence-based, and patient-, family-, and community-oriented. Academic institutions formed strong partnerships with many stakeholders (e.g., purchasers of health care services) to make the Collaborative Care approach work. In addition, there were several other important keys to Collaborative Care's success, such as the full integration of clinical research with clinical care and the restoration of trust in the health care enterprise. The author returns to reality and the 1990s. He challenges academic medicine to pursue the Collaborative Care vision, saying that "we should not accept without challenge what we know to be abominable just because it appears to be inevitable.... Our choice is to continue to struggle for survival as the environment around us gets harsher and harsher ... or to fix the environment" using the power of collaboration to unleash academic medicine's unlimited creativity and wisdom.