Health literacy: applying current concepts to improve health services and reduce health inequalities.

The concept of 'health literacy' refers to the personal and relational factors that affect a person's ability to acquire, understand and use information about health and health services. For many years, efforts in the development of the concept of health literacy exceeded the development of measurement tools and interventions. Furthermore, the discourse about and development of health literacy in public health and in clinical settings were often substantially different. This paper provides an update about recently developed approaches to measurement that assess health literacy strengths and limitations of individuals and of groups across multiple aspects of health literacy. This advancement in measurement now allows diagnostic and problem-solving approaches to developing responses to identified strengths and limitations. In this paper, we consider how such an approach can be applied across the diverse range of settings in which health literacy has been applied. In particular, we consider some approaches to applying health literacy in the daily practice of health-service providers in many settings, and how new insights and tools--including approaches based on an understanding of diversity of health literacy needs in a target community--can contribute to improvements in practice. Finally, we present a model that attempts to integrate the concept of health literacy with concepts that are often considered to overlap with it. With careful consideration of the distinctions between prevailing concepts, health literacy can be used to complement many fields from individual patient care to community-level development, and from improving compliance to empowering individuals and communities.

Twenty years since Ottawa and Epp: researchers' reflections on challenges, gains and future prospects for reducing health inequities in Canada

Resumo: November 2006 marked the 20-year anniversary of the Ottawa Charter for Health Promotion and Canada's Epp Report. Encapsulating the tenets of health promotion (HP), these publications articulated a vision for reducing health inequities, and described a policy framework for achieving this vision, respectively. These documents also triggered the launch of the population health (PH) field, focused on elucidating the empirical relationships between socioeconomic gradients and population health inequities. Over two decades, a rich HP/PH theoretical and evidentiary base on socioeconomic gradients in health has established. Yet, despite valuable contributions from Canadian researchers, insufficient headway has been made in this country to achieve the Charter's vision. There are numerous challenges to reducing population health inequities in Canada. Informational challenges include complexity of HP/PH evidence, and inadequate knowledge translation beyond traditional targets. Institutional challenges include the relative immunity of the healthcare sector to funding reductions, and the organization of policy responsibilities into silos. Concerns from non-healthcare sectors of 'health imperialism', and inter-governmental tensions are interest-related challenges, while ideological challenges include lack of media discourse on health inequities and a strong neo-liberal political climate. Gains have been made in Canada towards reducing health inequities. The HP/PH discourses are firmly entrenched in academic and policy spheres across the country, while several inter-sectoral policy initiatives are currently underway. HP/PH researchers could be more proactive in the knowledge-translation sphere by engaging other researchers outside of medicine and health, non-healthcare policy-makers, and the general public, vis-à-vis the media, on the health inequities knowledge base. Ultimately, significant and sustained progress will only be made if researchers and other champions recognize the inherently political aspect of their work and understand how to overcome ideologically driven resistance. (AU)

Survival and growth of Palaemonetes argentinus (Decapoda; Caridea) exposed to insecticides with chlorpyrifos and endosulfan as active element.

Pesticides with chlorpyrifos and endosulfan as active element are used for pest control on agricultural lands and are high-risk inputs in aquatic systems. The acute toxicity of these insecticides in the freshwater prawn Palaemonetes argentinus was evaluated. The results were used to determine the lowest observed-effect and no observed-effect concentrations. Individual growth of prawns in relation to chlorpyrifos and endosulfan exposure was analyzed. LC(50) values to chlorpyrifos and endosulfan exposure were 2.98 microg L(-1) and 14.10 at 24 hours and 0.49 microg L(-1) and 6.28 microg L(-1) at 96 hours of exposure, respectively. The size increment of prawns was the same in all treatments; cephalothorax length increased linearly per molt. The intermolt period was influenced by the toxic effect of pesticides during rearing time, and this decreased with the molt cycles compared with the normal growth pattern. The results suggest that juveniles of P. argentinus are sensitive to chlorpyrifos and endosulfan pollution.

Stress in police officers: a study of the origins, prevalence and severity of stress-related symptoms within a county police force.

BACKGROUND: High levels of stress-related illness are causing concern across industry. Against a background of impending legislative moves to try to improve this situation, there is a need to identify key work-related stressors. Police work tends to be regarded as inherently stressful because of the personal risk of exposure to confrontation and violence and the day-to-day involvement in a variety of traumatic incidents. As a result, high levels of stress-related symptoms might be expected in this population. OBJECTIVE: To examine the sources of stress-related symptoms within police officers and measure the prevalence of significant associated mental ill-health. METHOD: A cross-sectional questionnaire survey of a population of 1206 police officers was performed to assess levels of strain associated with a series of potential home and work related stressors. Participants were then split into low and high scoring groups on the basis of a General Health Questionnaire (GHQ) threshold score in order to identify those stressors most associated with mental ill-health effects. RESULTS: Occupational stressors ranking most highly within the population were not specific to policing, but to organizational issues such as the demands of work impinging upon home life, lack of consultation and communication, lack of control over workload, inadequate support and excess workload in general. The high scoring group constituted 41% of the population and differed significantly from those with low scores in perception of all stressors, ranking both personal and occupational stressors more highly, and from personality constraints appeared significantly more 'stress-prone'. A significant association between gender and mental ill-health was found, with females more likely to score more highly on the GHQ than males. CONCLUSION: This study confirms previous findings of organizational culture and workload as the key issues in officer stress. Given that the degree of symptomatology appears to be worsening, management action is required. Further research is indicated within the police population into a possible increased susceptibility in female officers.

Form and content: looking at visual features of television.

Television viewing at home by 50 individuals in 5 age groups (2-, 5-, 8-, 12-year-olds, and adults) was recorded on 1-s time-lapse videotapes over 10-day periods. Coding was based on 5-min point samples. Analysis examined looking at the TV screen in relation to the visual presence of the features cuts, movement, animation, man, woman, child, and nonhuman; content features were child vs. adult programming and overt purposeful character behavior. Cuts, movement, and overt purposeful character behavior were positively related to looking independent of child vs. adult programming. Associations with looking for the remaining features depended on the viewer's age or sex or type of content within which they occurred.

Waterborne transmission of Cryptosporidium, Cyclospora and Giardia.

Waterborne transmission of Cryptosporidium, Cyclospora, and Giardia has been associated with numerous recent outbreaks of diarrheal disease. Epidemiologic evidence shows that many community-acquired infections originate from public water sources. Drinking water, even when chlorinated and filtered, has been implicated in several outbreaks. Cryptosporidium and Cyclospora are resistant to chlorine. Giardia cysts are not killed immediately by chlorine and are less susceptible than most other organisms. Swimming pools and other recreational waters have also been implicated as transmission sources. All 3 organisms pose a challenge to the water industry, as they are difficult to detect in water when small numbers of cysts or oocysts are present. Small numbers of these organisms can cause disease; therefore, the clinical laboratory must be vigilant in screening, identifying, and reporting outbreaks of illness due to these protozoa.

Emerging intestinal protozoa: a diagnostic dilemma.

Increasing isolation of Cryptosporidium, Cyclospora, and microsporidia from immunocompromised patients with severe diarrhea has prompted study of these organisms. Only recently recognized as human pathogens, they have also been associated with several waterborne outbreaks of diarrhea in immunocompetent individuals. Cryptosporidium and Cyclospora have been shown to be transmitted through fecally contaminated food and water. The mode of transmission for microsporidia is still unclear. While the life cycle and pathogenesis of Cryptosporidium are beginning to be understood, the microsporidia and Cyclospora are less well elucidated. The laboratory diagnosis of these protozoa is difficult. The routine ova and parasites screen does not include screening for them. Many microscopic methods, including wet mounts, modified acid-fast and trichrome stains, and immunofluorescence methods have been shown to be effective screening methods in the hands of experienced microscopists. Enzyme immunoassay and polymerase chain reaction methods also show promise. The proper identification of these pathogens rests with well-trained laboratory personnel. As appropriate treatment differs for each genus, communication between the laboratory and the physician is vital to the recovery of the patient.

Differential expression of lymphocyte homing receptors by human memory/effector T cells in pulmonary versus cutaneous immune effector sites.

The heterogeneous expression of lymphocyte homing receptors (HR) by the (CD45RA(low)/RO(high)) memory/effector T cell population in the human is thought to define subsets with tissue-selective recirculatory potential. To investigate further the localization characteristics of these T cells, we used multiparameter flow cytometry to quantitate T cell subsets defined by expression of the skin-selective HR called the cutaneous lymphocyte-associated antigen (CLA), the peripheral lymph node (PLN) HR L-selectin, the mucosal-associated HR alpha 4 beta 7-integrin, and the mucosal-associated adhesion molecule alpha e beta 7-integrin in either cutaneous or pulmonary immune effector sites and corresponding peripheral blood. Compared to peripheral blood, skin T cells were highly enriched for the CLA+/L-selectin+/alpha e beta 7-integrin- memory/effector subset, whereas lung memory/effector T cells were predominantly CLA-to low L-selectin-, and almost half were alpha e beta 7-integrin+. alpha 4 beta 7-integrin expressing memory/effector T cells were diminished in both skin and lung, suggesting that this HR is not a major participant in determining localization specificity in either of these sites. The characteristic pulmonary T cell HR phenotype did not significantly differ between the normal subjects and those with pulmonary inflammatory disease, and did not correlate with markers of T cell activation. Induction of a rapid up-regulation of pulmonary inflammation via intrabronchial allergen challenge in asthmatic patients tended to decrease localization specificity, resulting in a more general importation of memory/effector subsets. Taken together, these results suggest that tissue microenvironments play a major role in determining the character of local T cell infiltrates via their ability to import and retain memory/effector subsets selectively or, more generally, depending on the intensity of local inflammatory stimuli.

The role of peripheral sudomotor blockade in the treatment of patients with sympathetically maintained pain.

The aim of the present study was to investigate the role of the peripheral cholinergic system in patients with sympathetically maintained pain (SMP). Thirty-three patients with SMP were given Bier's block with 0.6 mg of atropine in 10 ml of saline or 10 ml of saline in a randomised double-blind manner. Pain intensity, pain relief and mood were assessed before and after each block using the visual analogue scale (VAS). In addition pain intensity was assessed at the same time using a categorical scale (CS). There was at least 1 week between each injection, and during this week the patients reported their pain intensity daily, using the CS. Three patients failed to complete both wings of the study and thus the results of the remaining 30 patients were analysed using the Mann-Whitney U test and the Wilcoxon signed-rank test. No significant difference was found between atropine and saline on any parameter.

Control of lymphocyte recirculation in man. I. Differential regulation of the peripheral lymph node homing receptor L-selectin on T cells during the virgin to memory cell transition.

Conventional virgin lymphocytes of a given class show relatively homogeneous recirculation through secondary lymphoid tissues, whereas memory/effector populations are composed of distinct subsets with differential, often tissue-selective migratory capability. In keeping with these observations, CD45RAhigh/ROlow "virgin" T cells in human peripheral blood uniformly express the peripheral lymph node homing receptor (HR) L-selectin, whereas among the CD45RAlow/ROhigh "memory/effector" subset, the expression of this HR is bimodal. To investigate the mechanisms responsible for the generation of memory/effector T cell subsets with differential homing potential, we developed a multiparameter flow cytometric technique that defines a common pathway of post-thymic T cell differentiation in secondary lymphoid tissues. Our analyses indicate that the virgin to memory T cell transition is characterized by a stepwise, unidirectional progression through distinct CD45RA+/RO+ intermediates that allow the in vivo discrimination of early, middle, and late transitional T cells. In normal peripheral blood, few T cells with a transitional phenotype are identified, but in secondary lymphoid tissues, 2 to 10% of T cells have this phenotype, including those CD45RA+ T cells that 1) are morphologically blasts, 2) are in S or G2/M phase of the cell cycle, or 3) express activation Ag. General adhesion molecules (LFA-1, LFA-3, ICAM-1) are uniformly up-regulated concordant with changes in T cell expression of CD45RA/RO in all tissues examined. Early in the transition, L-selectin is also uniformly up-regulated, but in subsequent stages, T cell expression of this HR is preferentially down-regulated in mucosal lymphoid tissues, and retained in peripheral lymph node. Differential regulation of L-selectin can also be demonstrated in vitro by the activation of virgin T cells in the presence of specific cytokines--IL-2 induces L-selectin down-regulation, whereas IL-6 and particularly TGF-beta 1 promote L-selectin up-regulation. Taken together, these findings support the hypothesis that local microenvironments within particular secondary lymphoid tissues influence HR expression at the time of CD45RA/RO conversion, and thereby contribute to the formation of CD45RAlow/ROhigh memory/effector T cell populations with tissue-selective homing behavior.

Control of lymphocyte recirculation in man. II. Differential regulation of the cutaneous lymphocyte-associated antigen, a tissue-selective homing receptor for skin-homing T cells.

Recent work indicates that a novel homing receptor (HR)/endothelial ligand pair--the cutaneous lymphocyte-associated Ag (CLA) and E-selectin--is involved in targeting a unique skin-associated subpopulation of memory T cells to cutaneous sites of chronic inflammation. To investigate the regulatory mechanisms responsible for the generation of a memory T cell subset with skin-selective homing capability, we used multiparameter flow cytometry to assess the expression of CLA on T cells during initial T cell activation in secondary lymphoid tissues (the virgin to memory transition), and upon reactivation in skin. Our analyses indicate that in vivo induction of CLA (and E-selectin-binding ability) first occurs during the virgin to memory transition, and is regulated in a highly tissue-selective manner. The frequency of CLA expression on CD45RA+/RO+ transitional T cells within skin-associated peripheral lymph nodes was > fivefold higher than within the mucosal microenvironment of the appendix. In keeping with its role as a skin-selective homing receptor, levels of cell-surface CLA on T cells obtained from cutaneous blisters overlying delayed-type hypersensitivity sites were a mean 23-fold higher than on corresponding peripheral blood T cells, including all time points of lesional evolution. However, comparisons of CLA expression on resting vs activated skin blister T cells (HLA-DR - vs +, respectively) indicated that CLA expression, which is already quite high on the resting subset, appeared to be further up-regulated upon activation in skin. The critical involvement of local microenvironments in the regulation of CLA expression was also supported by in vitro studies demonstrating the necessity of specific secondary signals for the induction of CLA glycoproteins on mitogen-activated T cells. CLA up-regulation on both the virgin and memory T cell subsets was dependent on the presence of TGF-beta 1 (or, to a lesser extent, IL-6), but not a wide variety of other cytokines. Thus, the development of the CLA+ memory T cell subset is likely a product of the cumulative experience of those T cells with respect to local microenvironments at previous sites of activation, perhaps involving differential availability of bioactive TGF-beta 1 and/or IL-6 (both cytokines produced in skin). Repeated activation in skin or skin-associated peripheral lymph nodes may act to reinforce CLA expression on T cells functionally-associated with skin, and thus enhance the functional efficiency of these cells by preferentially focusing their recirculation to the skin or related sites.

Reciprocal interactions between epithelium, mesenchyme, and epidermal growth factor (EGF) in the regulation of mandibular mitotic activity in the embryonic chick.

Mandibular epithelia and mesenchyme from chick embryos of Hamburger and Hamilton (H.H.) stage 18-25 were cultured intact, in isolation, or in recombinations in the presence or absence of 5-40 ng/ml epidermal growth factor (EGF). 3H-thymidine labelling demonstrated that mesenchyme influenced epithelial mitotic activity and vice versa. EGF can substitute for the epithelial effect. The stimulation of mesenchymal proliferation by H.H. 18 and 22 epithelia correlated with high levels of epithelial proliferation. Epithelial proliferation was low at H.H. 25 and unaffected by mesenchyme or by EGF. Epithelial stimulation of mesenchymal proliferation began earlier (H.H. 18) than did mesenchymal stimulation of epithelial proliferation (H.H. 22); i.e., within the ages tested, the epithelium initiated these reciprocal mitogenic interactions. That epithelial dependence on mesenchyme coincided with epithelial bone-evoking properties, suggested a) that mesenchyme promotes or maintains epithelial bone-promoting activity and b) that the critical differentiative influence of epithelium on mesenchyme is a mitogenic one. The temporal correlation between a sharp decline in mesenchymal proliferation and termination of the osteogenic epithelial-mesenchymal interaction at H.H. 25 further supports a connection between epithelial maintenance of mesenchymal proliferation and epithelial evocation of osteogenesis.

Changes in the advertised demand for nurse practitioners in the United States, 1975-1986.

Legislative and reimbursement policies have presented barriers to employment and autonomy for nurse practitioners since the beginning of the nurse practitioner movement in 1965. Greater resistance to NPs in the 1980s was predicted because of a sluggish economy and burgeoning oversupply of physicians. In this study, quantitative content analysis was used to examine 1,022 job advertisements published in The Nurse Practitioner: The American Journal of Primary Health Care from 1975 to 1986. Unstandardized regression analysis was used to compare changes in the demand for nurse practitioners by region, employment setting, job duties, specialty, employment time (full- or part-time), degree required or preferred for the position, and whether the ad specified a joint practice arrangement. Contrary to the predictions of past research, the demand for nurse practitioners increased during this time period, with a greater tendency toward primary care.

Chondrogenesis of mandibular mesenchyme from the embryonic chick is inhibited by mandibular epithelium and by epidermal growth factor.

This study documents the role of mandibular epithelium and epidermal growth factor (EGF) in the initiation, maturation and maintenance of Meckel's cartilage using percent 3H-thymidine-labelled cells as an index of proliferative activity and distribution of labelled cells, chondrocyte size and relative amount of extracellular matrix as indices of chondrogenesis. Mandibular mesenchyme from embryos of H.H. stages 18, 22, 25 was cultured for 2 to 10 days (a) unseparated from mandibular epithelium, (b) in isolation, or (c) after recombination with mandibular epithelium in the presence or absence of 5-40 ng/ml EGF. Epithelium delayed both initiation of chondrogenesis and maturation of already formed cartilage. The 3H-thymidine-labelling index was reduced in cartilage that differentiated in the presence of mandibular epithelium. Epithelium influenced the timing of mesenchymal differentiation (a) by delaying cytodifferentiation through prolonging high levels of proliferation, and (b) by directly affecting differentiation itself. EGF, especially at 10-20 ng/ml, affected both proliferation of mesenchyme and chondrogenesis in mesenchyme cultured with or without epithelium. All observed effects of epithelium on intact tissues could be duplicated by exposing isolated mesenchyme to EGF at 10 ng/ml, i.e. a role for EGF in chondrogenesis is suggested.

Interaction of inhibitin with the human erythrocyte Na+(Li+)i/Nao+ exchanger.

The kinetic interactions of inhibitin, a peptide isolated from cultured leukaemic promyelocytes, with erythrocyte Na+/Na+ and Na+/Li+ exchanges have been investigated. Inhibitin (1 microM) reduced the ouabain- and bumetanide-resistant sodium efflux and influx by equivalent amounts indicating an inhibitin-sensitive exchange component of 0.52 mmol/l per h. This value was not significantly different from that measured as the difference in sodium-rich (140 mM) and sodium-free media (0.49 mmol/l per h). Similarly, the inhibitin-sensitive lithium efflux was equivalent to the sodium/lithium countertransport component (0.36 vs. 0.34 mmol/l per h), indicating that both exchanges were mediated by the same transport process, which is inhibitin-sensitive. The dose-response curve revealed the presence of a single inhibitin binding site per exchanger with a Ki of 2.10(-7) M. In kinetic inhibition studies, inhibitin (0.1 microM) decreased the Vmax of ouabain- and bumetanide-resistant sodium efflux with no effect on the Km for external sodium, i.e., inhibitin displayed a non-competitive mechanism of action. These findings indicate that inhibitin interacts with the Na+(Li+)i/Nao+ exchanger at a site distinct from the sodium binding site.

Assessing the clinical significance of anti-Cra and anti-M in a chronically transfused sickle cell patient.

An alloantibody to a high-incidence antigen, associated with multiple other alloantibodies, made it impossible to supply antigen-negative red blood cells (RBCs) for a chronically transfused sickle cell anemia patient. Anti-Cra,-E,K,-S, -Fya, -Fyb, as well as anti-M reactive at 37 degrees C and in the antiglobulin phase of testing, were identified in the patient's serum. An extensive search of rare donor files at the American Red Cross and at the American ASsociation of Blood Banks (AABB) failed to identify Cr(a-),M-,E-,K-,S-, Fy(a-b-) donors. Various studies were performed to predict the clinical significance of the anti-Cra and anti-M. Results of 51chromium survival studies showed 91.8 percent survival at 10 minutes and 87.2 percent survival at 60 minutes with Cr(a +),M-, K-,S-,Fy(a-b-) donors. Various studies were performed to predict the clinical significance of the anti-Cra and anti-M. Results of 51chromium survival studies showed 91.8 percent survival at 10 minutes and 87.2 percent survival at 60 minutes with Cr(a +),M-,E -,K-,S-,Fy(a-b-) red cells, suggesting that immediate destruction of transfused CrCa+) red cells would he unlikely. However, further analysis revealed diminished long-term survival of the donor's red cells with only 60.1 percent recovery at six days (T 1/2 = 12 days) and 10.8 percent at 14 days (T 1/2 = 4.5 days). A monocyte- monolayer assay (MMA) indicated that both the anti-Cra (5.9%) and anti-M (18%) would probably be clinically significant (normal value 0-3%). Mass screening continues at several blood centers for Cr(a-),M-, E-,K-,S-,Fy(a-b-) donors. However, if no suitable donors are found, the results of the 51chromium survival studies and the MMA support the decision to transfuse this patient with Cr(a+),M-,F(a- b-),S-,K- ,E- red cells, if necessary.

Musculoskeletal tumors: improved depiction with linear combinations of MR images.

With postprocessing, the authors produced a single hybrid image that combines the complementary information in conventional T1- and T2-weighted magnetic resonance (MR) images. A 1-T MR imager was used to produce T1- and T2-weighted images (repetition time, msec/echo time, msec: 500/30, 1,500/120) of patients with various primary bone tumors. Various weighted sums and differences of these images were then formed. Weighted subtraction allowed formation of hybrid images with high contrast between tumor and all adjacent normal tissues (muscle, fat, bone marrow), unlike the original T1- and T2-weighted images. Certain weighted sums of the acquired images simultaneously display the high signal-to-noise and clear anatomic detail of the T1-weighted technique along with the high contrast between extraosseous tumor and muscle of the T2-weighted image. A single hybrid MR image can contain useful characteristics both of T1- and T2-weighted images, making it easier for one to detect the extent of an abnormality.

Television viewing at home: age trends in visual attention and time with TV.

The TV-viewing behavior of 99 families with young children was videotaped by automated time-lapse recording equipment placed in homes for 10-day periods. The 99 families comprised 460 individuals from infants to 62 years of age. Time-sample analyses of 4,672 hours of recordings indicated that the TV-viewing room contained no viewers 14.7% of the time that the TV was on. There were no age trends in time spent with television. Percent visual attention to television increased greatly across the preschool years, leveled off at about 70% during the school-age years, and declined in adulthood. Men looked at the TV more than women. There were no significant correlations between time spent with TV and percent of visual attention to TV. The increase in visual attention to television during the preschool years is consistent with the theory that TV program comprehensibility is a major determination of attention in young children.