BACKGROUND: Travel-related barriers to human immunodeficiency virus (HIV) care, such as commute time and mode of transportation, have been reported in the United States. OBJECTIVE: The objective of the study was to investigate the association between public transportation use and HIV care attendance among a convenience sample of Atlanta-based, HIV-positive men who have sex with men (MSM), evaluate differences across regions of residence, and estimate the relationship between travel distance and time by mode of transportation taken to attend appointments. METHODS: We used Poisson regression to estimate the association between use of public transportation to attend HIV-related medical visits and frequency of care attendance over the previous 12 months. The relationship between travel distance and commute time was estimated using linear regression. Kriging was used to interpolate commute time to visually examine geographic differences in commuting patterns in relation to access to public transportation and population-based estimates of household vehicle ownership. RESULTS: Using public transportation was associated with lower rates of HIV care attendance compared to using private transportation, but only in south Atlanta (south: aRR: 0.75, 95% CI 0.56, 1.0, north: aRR: 0.90, 95% CI 0.71, 1.1). Participants living in south Atlanta were more likely to have longer commute times associated with attending HIV visits, have greater access to public transportation, and may live in areas with low vehicle ownership. A majority of attended HIV providers were located in north and central Atlanta, despite there being participants living all across the city. Estimated commute times per mile traveled were three times as high among public transit users compared to private transportation users. CONCLUSIONS: Improving local public transit and implementing use of mobile clinics could help address travel-related barriers to HIV care.
The perceptions and experiences among general practitioners (GPs) and nurses in identifying female patients experiencing domestic violence and referring patients to specialist agencies need to be clarified. Eleven GPs and six nurses participating in a multidisciplinary domestic violence training and support programme in east London and Bristol were interviewed. All participants recognised that identification of women experiencing domestic violence and offering support were part of their clinical roles. Perceived differences between GPs and nurses, including time constraints, level of patient interaction, awareness of patients' social history, scope of clinical interview, and patient expectations were used to explain their levels of domestic violence inquiry. Barriers to inquiry included lack of time, experience, awareness of community resources, and availability of effective interventions postdisclosure. Longstanding relationships with patients were cited both as barrier and facilitator to domestic violence disclosure. Some nurses reported discomfort with direct inquiry due to the lack of clinical experience in responding to domestic violence despite satisfaction with training. Future domestic violence training programmes should take into account potential differences between GPs and nurses, in terms of their clinical roles and the unique barriers encountered, in order to improve self-efficacy and to facilitate collaborative and effective responses.
Background: Patient diaries and pain scales can capture the course and complications of pain managed at home in children. The Faces Pain Scale-Revised (FPS-R) is a validated scale showing reliability in children, but it has not been validated in children with sickle cell disease (SCD). Objective: The purpose of this study was to evaluate comprehension and usability of an electronic modified version of the FPS-R among pediatric patients with SCD.
Methods: This was a cross-sectional, qualitative study involving in-person interviews with children/adolescents from the USA and their parents/legal guardians. Interviews involved cognitive debriefing and usability testing of the FPS-R.
Results: In total, 22 children with SCD aged 4–17 years participated. Children aged 4–6 were generally unable to demonstrate clear understanding of the FPS-R and its response scale. Overall, children aged ≥7 years understood the instrument and could complete it on the electronic device, although children aged 7–8 often needed assistance from the parent. Children aged 9–17 years were able to read and complete the instrument independently. Most participants considered the electronic device easy to use.
Conclusions: The FPS-R was shown to be a comprehensible and usable pain measure for children aged 7–17 with SCD and to be beneficial for future clinical studies.
OBJECTIVES: Targeted parental education reduces acute visits for pediatric asthma. Whether the use of education sources readily available to parents relates to nonadherence to asthma treatments is uncertain. This study describes asthma education sources and assesses for a relationship to risks for nonadherence. METHODS: Caregivers of children with asthma completed a cross-sectional survey at 2 sites: a pediatric emergency department (ED) and an asthma clinic (AC). Measured items included the use of 7 education sources (primary care, ED, AC, friends/family, TV, internet, and printed materials), scores of child asthma morbidity, parental asthma knowledge, and risks for nonadherence, the primary outcome. Recruitment site, preferred language (English/Spanish), and demographics were recorded. Descriptive statistics, bivariate analyses, and multivariate regressions were performed. RESULTS: A total of 260 participants, 158 from ED and 102 from AC, used a variety of education sources. They reported 4.1 (2.0) of 13 risk factors for nonadherence, with more risks in ED parents than AC parents (4.8 vs 3.9, P < 0.001). The ED parents worried more about medications and had worse access to primary care. The regression did not show a significant relationship between education sources and risks for nonadherence, but ED recruitment, Spanish language, and worse morbidity contributed to higher risks. CONCLUSIONS: The use of more asthma education sources was not associated with reduced risks for nonadherence. Of the education sources, a primary care provider may benefit ED parents, who also need refills and education about medications. Spanish-speaking parents report more risks for nonadherence, warranting further study of Spanish-language asthma education.
Objective. To assess the reliability and criterion and construct validity of the self-administered Brief Index of Lupus Damage (SA-BILD), a patient-reported measure of organ damage in systemic lupus erythematosus (SLE). Methods. The validity of the SA-BILD was assessed using data from the Georgians Organized Against Lupus (GOAL) survey. GOAL is a longitudinal cohort of SLE patients predominantly derived from the Georgia Lupus Registry, a population-based registry established in Atlanta, Georgia. In total, 711 participants with documented SLE completed the SA-BILD. To test reliability, the SA-BILD was readministered to 32 patients. Criterion validity was examined in 150 respondents for whom the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) was also completed. Construct validity was assessed among 711 GOAL participants by dividing the SA-BILD scores into quartiles and examining the association with demographics, health status, and health care utilization. Results. The test-retest correlation score was 0.93 (P < 0.0001), the item-by-item agreement with the SDI was >80% for most SA-BILD items, and the Spearman's rho correlation coefficient for the SDI and SA-BILD was moderately high (ρ = 0.59, P < 0.0001). SA-BILD scores showed significant associations in the expected directions with age, disease duration, disease activity, overall health, comorbidity index, and physician visits. Conclusion. The SA-BILD was reliable and had very good or good criterion validity compared with the SDI when tested in a predominantly African American cohort of US SLE patients. Associations of SA-BILD scores with sociodemographics and health status were consistent with previous studies. These findings support the use of the SA-BILD as a valid measure of patient-reported damage in SLE.
Unintentional falls in older adults (persons 65 and older) impose a significant economic burden on the healthcare system. Methods for calculating state specific healthcare costs are limited. This study describes two methods to estimate state-level direct medical spending due to older adult falls and explains their differences, advantages and limitations.
Management of sepsis is time sensitive. The faster therapy is initiated, the higher the likelihood for a positive outcome. While the optimal treatment for severe sepsis and septic shock is multifactorial, a cornerstone of management includes placement of a central venous catheter (CVC) in order to administer vasoactive agents, and measure central venous pressure and central venous oxygenation when appropriate. In this issue of Critical Care Medicine, Theodoro et al examine the utilization and timing of CVCs in patients admitted from the ED with a diagnosis of sepsis or respiratory arrest. A total of 25% of all ED admissions that underwent CVC placement at 310 hospitals in California between 2003 and 2006 were analyzed. Procedures were categorized based on when a CVC was inserted, with insertion on day 0 of hospitalization classified as emergent, insertion on days 1–2 classified as urgent, and insertion on day 3 or beyond classified as late.
Social support is an important mechanism for improving self-management, although little is known about its role in epilepsy self-management. We examined the type of support provided to people with epilepsy and its influence on self-management. We conducted in-depth interviews with 22 people with epilepsy and 16 support persons, representing 14 pairs and 10 unpaired individuals. We analyzed the data using principles of grounded theory. Supporters, who were mainly parents and spouses, aided people with epilepsy in every dimension of self-management. Support for self-management occurred along a continuum from person with epilepsy-led management to support person-led management. Where the pairs fell on the continuum depended on developmental stage, relationship type, and relationship dynamics. Seizure control shaped individuals' experiences with self-management and support within each group. The self-management continuum provides a new aspect that can be integrated into existing models of self- and family management.
Aim. Caregiver burden (CB) in epilepsy constitutes an understudied area. Here we attempt to identify the magnitude of this burden, the factors associated with it, and its impact to caregiver quality of life (QOL). Methods. 48 persons with epilepsy (PWE) underwent video-EEG monitoring and their caregivers completed questionnaires providing demographic, disease-related, psychiatric, cognitive, sleep, QOL, and burden information. Results. On regression analysis, higher number of antiepileptic drugs, poorer patient neuropsychological performance, lower patient QOL score, and lower caregiver education level were associated with higher CB. Time allocated to patient care approximated but did not attain statistical significance. A moderate inverse correlation between CB and caregiver QOL physical component summary score and a stronger inverse correlation between CB and caregiver QOL mental component summary score were seen. Conclusion. In a selected cohort of PWE undergoing video-EEG monitoring, we identified modest degree of CB, comparable to that reported in the literature for other chronic neurological conditions. It is associated with specific patient and caregiver characteristics and has a negative effect on caregiver QOL.
A gap exists between the development and uptake of evidence-based health promotion programs in health care settings. One reason for this gap is lack of attention to organizational readiness. The objective of this study was to assess organizational readiness to implement the Chronic Disease Self-Management Program in dialysis facilities. Survey data were collected from dialysis staff using a semi-structured Organizational Readiness for Implementing Change questionnaire. Change efficacy and change commitment scale ratings were all above 3.0, indicating a moderate level of readiness among staff. Profession and level of education were significantly associated with mean change efficacy scale ratings. Textual data revealed benefits to patients, implementation barriers and facilitators, and the influence of facility environment and culture. The findings of the current study suggest that additional efforts to advance the implementation of evidence-based health promotion programs in dialysis facilities are needed.