Care burden and related factors among informal caregivers of patients with amyotrophic lateral sclerosis.

Objective: Amyotrophic lateral sclerosis (ALS) affects the life of the family caregiver as well as the patient. This study aimed to determine the care burden and related factors among family caregivers of Turkish ALS patients. Methods: This descriptive study was conducted with 108 ALS patients and their informal caregivers through face-to-face interviews at home. The data were collected using the ALS Functional Rating Scale, Zarit Burden Interview, European Quality of Life-Five Dimensions Questionnaire, Multidimensional Scale of Perceived Social Support, and the Hospital Anxiety and Depression Scale. Results: The mean age of the caregivers was 48.1 ± 13.4 years; the vast majority were female, and they were either spouses or children of the patients. While 49.1% reported moderate or severe burden, the quality of life was moderate (mean 70.4 ± 22.8). The caregiver burden was related to sex and the functional state of the patient, as well as caregiver factors such as the relation to the patient, sex, health status, time spent for care, and living in the same house with a limited environment. Walking ability, percutaneous endoscopic gastrostomy, tracheostomy, and communication problems were not associated with the burden. Furthermore, burden was associated with the caregiver's quality of life, social support, anxiety, and depression. Conclusions: The present study draws attention to the fact that the care burden in family caregivers of ALS patients is high and their quality of life is impaired. Our findings reveal that not only ALS patients but also caregivers need to be supported with an organized and planned system.

Pros and cons of botulinum toxin injection therapy in cerebral palsy: A qualitative study exploring caregivers' perspective.

BACKGROUND: To describe and understand the experiences and beliefs of caregivers of children with cerebral palsy following botulinum toxin injection. METHODS: A descriptive case study approach with focus group interviews was employed. A semi-structured questionnaire was conducted to collect data. Twenty-one caregivers of children (3-13 years old) with cerebral palsy were recruited with a maximum variation sampling strategy to gain insight through different perspectives. Qualitative analysis with verbatim transcripts was analysed using a thematic approach. FINDINGS: Four themes emerged from qualitative analyses: acceptance of diagnosis, perceptions about treatment, caregivers' experiences with the health environment, and feelings and thoughts after the treatment. CONCLUSIONS: This study highlights caregivers' requests for information about the possible long-term effect of botulinum toxin, as well as information and support to provide the best rehabilitation programme immediately after injection.

Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries.

OBJECTIVE: To explore dementia management from a primary care physician perspective. DESIGN: One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist. SETTING: Twenty-five European General Practice Research Network member countries. SUBJECTS: Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories. MAIN OUTCOME MEASURES: Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines. RESULTS: Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories. CONCLUSIONS: Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

Family physicians' views on their role in the management of childhood obesity: a mixed methods study from Turkey.

BACKGROUND: Childhood obesity (CO) is a high priority issue due to its serious health consequences and its rapid increase. OBJECTIVES: To examine the views of primary care physicians (family physicians, FPs) in Turkey regarding their role in the management of CO and the barriers they perceive. METHODS: Mixed methods approach. Data was collected in two major counties of Istanbul between February and May 2014. All Family Health Centres (FHCs) in the region were visited, and 180/284 FPs (63.4%) agreed to complete a structured questionnaire (22 questions). Of those, 48 FPs agreed to participate in in-depth interviews that were taken until saturation was 25. Quantitative data were analysed using descriptive statistics. For qualitative data, content analysis was applied to identify the themes. RESULTS: Most of the FPs (93.3%) agreed that they have a role in managing CO. Almost all FPs (98.3%) agreed that for the 0-4-year-olds height and weight measures should be taken. However, only 67.6% recommended this for children aged 5-15 years. The most common barriers in the management of CO were reported as lack of time (68.9%) and FHCs not being utilized for the care of children aged 5-15 years old (53.3%) in Turkey. In-depth interviews showed that FPs tend to limit their role to identifying the problem and making the family aware of it. CONCLUSION: Although FPs recognize primary healthcare as an appropriate setting for managing CO, they have concerns about being involved in the treatment.

Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries.

BACKGROUND: Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment. METHODS: Key informant survey. SETTING: Primary care practices across 25 European countries. SUBJECTS: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. MAIN OUTCOME MEASURES: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs' attitude of "trying to establish a diagnosis of dementia on their own." RESULTS: Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28-5.23). CONCLUSIONS: Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

Cross-cultural validation of the Turkish Four-Dimensional Symptom Questionnaire (4DSQ) using differential item and test functioning (DIF and DTF) analysis.

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is originally a Dutch 50 item questionnaire developed in primary care to assess distress, depression, anxiety and somatization. We aimed to develop and validate a Turkish translation of the 4DSQ. METHODS: The questionnaire was translated using forward and backward translation, and pilot testing. Turkish 4DSQ-data were collected in 352 consecutive adult primary care patients. For comparison, gender and age matched Dutch reference data were drawn from a larger existing dataset. We used differential item and test functioning (DIF and DTF) analysis to validate the Turkish translation to the original Dutch questionnaire. Through additional inquiry we tried to obtain more insight in the background of DIF in some items. RESULTS: Twenty-one items displayed DIF but this impacted only the distress and depression scores. Inquiry among Turkish people revealed that the reason for DTF in the distress scale was probably related to unfavourable socio-economic circumstances. On the other hand, the likely explanation for DTF in the depression scale appeared to be grounded in culturally and religiously determined optimistic beliefs. Raising the distress cut-offs by 2 points and lowering the depression cut-offs by 1 point ensures that individual Turkish 4DSQ scores be correctly interpreted. CONCLUSIONS: The Turkish translation of the 4DSQ (named: "Dört-Boyutlu Yakinma Listesi", 4BYL) measures the same constructs as the original Dutch questionnaire. Turkish anxiety and somatization scores can be interpreted in the same way as Dutch scores. However, when interpreting Turkish distress and depression scores, DTF should be taken into account.

Survey on a mammographic screening program in Istanbul, Turkey.

Breast cancers in Turkey tend to be diagnosed at advanced stages due to lack of organized comprehensive mammographic screening. In this study, factors associated with having a mammogram among healthy women of screening age in Bahcesehir county, a region in Istanbul, were investigated to assess the feasibility of organized breast cancer screening in Turkey. In this cross-sectional study, 659 healthy women aged between 40 and 69 years were surveyed. A multiple-choice questionnaire was used to obtain information regarding patient demographics, family history of cancer, and patient knowledge on mammographic screening. Factors associated with increased likelihood of having a mammogram included age older than 50 (OR=1.75; 95% CI=1.23-2.49), higher educational level (high school or university graduate; OR=1.55; 95% CI=1.07-2.25), and undergoing periodic gynecologic examinations (OR=5.53; 95% CI= 3.88-7.89). Women aged between 40 and 49 years, who were most likely to have a mammogram within the last 2 years were characterized by a higher educational level (OR=1.94; 95% CI=1.14-3.31), periodic gynecologic examinations (OR=4.06; 95% CI=2.53-6.51), and a first or second degree family history of breast cancer (OR=2.2; 95% CI= 1.06-4.50). In contrast, women aged between 50 and 69 years were more likely to have undergone mammography within the previous 2 years if they also had undergone periodic gynecologic examinations (OR=8.63; 5.04-14.77). Our findings suggest that women of lower educational level and those who do not undergo routine wellness visits with their gynecologist will need to be specifically targeted for educational outreach to achieve broad screening compliance within the population.

Factors associated with adolescents' smoking experience and staying tobacco free.

Introduction It is not expected that those who did not smoke during their adolescent years will start to smoke later in life. This study was planned to learn the thoughts of Turkish adolescents about staying tobacco free.Methods A descriptive study was conducted in 2007 with 866 adolescents aged 11 to 14 years. On a self-administered questionnaire, non-smoker students answered both multiple choice and open-ended questions about why they would not smoke in the future. The Chi-square test and logistic regression analysis was used for statistical assessment. For the answers to the open-ended questions, thematic analysis was applied.Results The mean age of the participants was 12.84 ± 1.14 years. The incidence of a smoking experience at least once in the participant's lifetime was 12% and the rate of current smoking was 3.6%. The most listed reasons for staying tobacco free were health problems directly related to smoking (64%), such as 'it can cause diseases' or 'it kills', negative effects of smoking other than health (51%), such as 'it smells bad' or 'it is toxic', and some subjective judgements related only with their self perceptions, such as 'I am happy and healthy' or 'it affects growth negatively' (20%).The most well-known problem related to tobacco use was lung cancer and the least well-known problems were bladder cancer and chronic bronchitis. Most of the smoking students (68%) were not aware that second-hand smoking was harmful (p=0.003). There were significant correlations between smoking experience and male gender, having a smoker in the household and low educational level of the mother or the father (p=0.000, p=0.018, p=0.022, p=0.044 respectively).Conclusion We suggest that the beliefs and perceptions of adolescents about smoking should be given as much consideration as the negative effects of cigarettes in planning smoking free messages.

A basic arthroscopy course based on motor skill training.

Aim of this study is to introduce, evaluate, and propose a basic arthroscopy training course with interactive methods as using bovine knees, joint models but mainly focusing on practices with motor skill-learning devices. This study presents the results of a skill training program which is based on "motor skill training" theory and using "bovine knees" to simulate a specific task as arthroscopy both in education and evaluation. The participants gave feedback regarding their expectations, fulfillment, and self-evaluation on the degree of their improvement levels, after which their skills were evaluated by an expert while they performed the arthroscopic procedure. During this evaluation of the task, a four-dimensional checklist which was prepared previously by the consensus of three experts was used, and a global grading of each rater was added at the end of the checklist. In this 2-day course, small group teaching sessions are integrated with active and experiential learning methods consisting of short presentations by the educators, demonstrations using joint models and audio-visual teaching material, and significant continuous feedback by the teachers during the proceedings. Participants' expectations and post-course feedback results were obtained using a brief questionnaire which involved mostly open-ended questions. The self-rating of "own basic diagnostic arthroscopy skill" on a scale of 0-10 was completed by the participants both previous to and following the course to establish a student-centered learning environment. Overall rating of the course was asked on a 1-5 (poor-excellent) Likert scale. The questioning of the participants who took part in the course during the last five terms involved a 100% feedback. The overall rating of the course was 4.36 ± 0.47 on the 1-5 scale. The majority of the participants (90%) mentioned that the course met their expectations. The most beneficial activities were accepted to be the arthroscopic procedure applications on bovine knee, repetition of the manipulations under the supervision of the trainers, continuous feedback by experienced staff, and chance for immediate correction during the procedures (35/64). Pre- and post-course self-ratings of the participants inquiring about their ability to perform an arthroscopy alone showed significant improvement (4.2 vs. 7.7 P = 0.000, paired samples t test). All participants were found to be competent in the evaluation of their diagnostic arthroscopy skills on bovine knees. To design a skill teaching course based on the needs of the trainees, focusing on basic motor skill training exercises, and using bovine knee as a simulator is a safe, inexpensive, humanistic, and replicable method that proves a foundation for basic arthroscopic skills learning prior to patient encounter.

Using theatre in education in a traditional lecture oriented medical curriculum.

BACKGROUND: Lectures supported by theatrical performance may enhance learning and be an attractive alternative to traditional lectures. This study describes our experience with using theatre in education for medical students since 2001. METHODS: The volunteer students, coached by experienced students, were given a two-week preparation period to write and prepare different dramatized headache scenarios during three supervised meetings. A theatrical performance was followed by a student presentation about history taking and clinical findings in diagnosing headache. Finally, a group discussion led by students dealt with issues raised in the performance. The evaluation of the theatre in education lecture "A Primary Care Approach to Headache" was based on feedback from students. RESULTS: More than 90% of 43 responding students fully agreed with the statement "Theatrical performance made it easier to understand the topic". More than 90% disagreed with the statements "Lecture halls were not appropriate for this kind of interaction" and "Students as teachers were not appropriate". Open-ended questions showed that the lesson was thought of as fun, good and useful by most students. The headache questions in the final exam showed results that were similar to average exam results for other questions. CONCLUSION: Using theatrical performance in medical education was appreciated by most students and may facilitate learning and enhance empathy and team work communication skills.

[Correlation of basic motor skills with arthroscopic experience]. / Temel motor becerilerin artroskopik deneyim ile iliskisi.

OBJECTIVES: One of the methods in motor skill teaching is to furnish the students with the individual skills drawn from the target procedure. This method requires identification and defining of all components of the target procedure. This study aimed to define basic motor skills composing arthroscopic skillfulness. METHODS: A total of 42 orthopedists (mean age 38+/-8 years) were enrolled. The study group was comprised of 17 experienced orthopedists working at least for 10 years as a specialist and performing more than 50 arthroscopic procedures per year. The control group included 25 young orthopedists or residents having an arthroscopic experience of less than three years. All the participants were assessed simultaneously and in the same experimental setting. Each participant was tested after having been shown to use in vitro skill development instruments simulating arthroscopic basic motor skills. RESULTS: Compared to the control group, the experienced group had significantly higher mean age (42 vs. 34.4 years), longer duration of arthroscopic experience (12.4 vs. 1.6 years), and greater number of the arthroscopies performed per year (93.9 vs. 26.9) (p=0.000). The mean anticipation time (p=0.028) and two-arm coordination time (p=0.043) were significantly shorter in the experienced group. In correlation analysis, duration of arthroscopic experience was correlated with the mean anticipation time (r=-0.41, p=0.008) and two-arm coordination time (r=-0.33, p=0.033). In addition, the mean anticipation time decreased significantly as the number of arthroscopies increased (r=-0.446, p=0.003). CONCLUSION: Some basic motor skills correlate with arthroscopic competence. The use of these motor skill instruments in arthroscopy training may aid to improve arthroscopic skills.

"I should live and finish it": a qualitative inquiry into Turkish women's menopause experience.

BACKGROUND: While bio-medically, menopause could be treated as an illness, from a psychosocial and cultural perspective it could be seen as a "natural" process without requiring medication unless severe symptoms are present.Our objective is to explore the perceptions of Turkish women regarding menopause and Hormone Therapy (HT) to provide health care workers with an insight into the needs and expectations of postmenopausal women. METHODS: A qualitative inquiry through semi-structured, in-depth interviews was used to explore the study questions. We used a purposive sampling and included an equal number of participants who complained about the climacteric symptoms and those who visited the outpatient department for a problem other than climacteric symptoms but when asked declared that they had been experiencing climacteric symptoms. The interview questions focused on two areas; 1) knowledge, experiences, attitudes and beliefs about menopause and; 2) menopause-related experiences and ways to cope with menopause and perception of HT. RESULTS: Most of the participants defined menopause as a natural transition process that one should go through. Cleanliness, maturity, comfort of not having a period and positive changes in health behaviour were the concepts positively attributed to menopause, whereas hot flushes, getting old and difficulties in relationships were the negatives. Osteoporosis was an important concern for most of the participants. To deal with the symptoms, the non-pharmacological options were mostly favoured. CONCLUSION: To our knowledge, this is the first qualitative study which focuses on Turkish women's menopausal experiences. Menopause was thought to be a natural process which was characterised by positive and negative features. Understanding these features and their implications in these women's lives may assist healthcare workers in helping their clients with menopause.