RESUMEN
BACKGROUND: Within North America and worldwide, drug-related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply of illicit substances to reduce overdoses with hopes of replacing substances obtained from the illicit drug market. Drug users1 should be at the centre of program and policy decisions related to the development and implementation of safer supply. Yet, there is little empirical research that conceptualizes effective safer supply from their perspectives. METHOD: Within a community based participatory approach to research, we conducted a concept mapping study to foreground the perspectives of drug users and develop a conceptual model of effective safer supply. Our team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The focused prompt developed by the team was: "Safe supply would work well if " Sixty-three drug users participated in three rounds of focus groups as part of the concept mapping process, involving brainstorming, sorting, rating and naming of themes. RESULTS: The concept mapping process resulted in six clusters of statements: 1) Right dose and right drugs for me; 2) Safe, positive and welcoming spaces; 3) Safer supply and other services are accessible to me; 4) I am treated with respect; 5) I can easily get my safer supply; and 6) Helps me function and improves my quality of life (as defined by me). The statements within each cluster describe key components central to an effective model of safer supply as defined by drug users. CONCLUSION: The results of this study provide insights into key components of effective safer supply to inform planning and evaluation of future safer supply programs informed by drug user perspectives.
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COVID-19 , Sobredosis de Droga , Drogas Ilícitas , Humanos , Calidad de Vida , Reducción del Daño , Sobredosis de Droga/prevención & controlRESUMEN
BACKGROUND: Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes. METHODS: StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals. RESULTS: The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (- 0.08% (- 0.31 to 0.16) (IFCC - 0.82 mmol/mol (- 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was - 0.71% (- 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful. CONCLUSIONS: Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes. TRIAL REGISTRATION: Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.
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Teléfono Celular , Diabetes Mellitus Tipo 2 , Envío de Mensajes de Texto , Adulto , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Humanos , Cumplimiento de la Medicación , SudáfricaRESUMEN
BACKGROUND: The inclusion of people with lived and living experience of substance use is essential to effective and client-centered harm reduction services and strategies. The aim of this study is to critically examine and characterize peer worker roles and the definition, recognition, and support for these roles within harm reduction organizations. METHODS: Fifteen interviews were conducted with peer workers-people with lived and living experience of substance use engaged in harm reduction service delivery-in British Columbia, Canada. An interpretive descriptive approach to data analysis was used to generate themes that best illustrated the roles of peer workers. FINDINGS: Two interrelated and overarching themes are presented: (1) peer work in practice; (2) organizational support. Our findings illustrate that peer work is incredibly complex and demanding, requiring peers to be at the forefront of support within their communities while simultaneously navigating the oppressive structures within which they work. While peer workers found a high degree of purpose and meaning in their day-to-day work, their roles lacked definition within organizations, which produced feelings of ineffectiveness and being undervalued. A lack of organizational understanding and recognition of their roles was evident from unclear "peer" role titles, a lack of role communication and expectations, the representation of experiential knowledge, and a lack of role support and training. CONCLUSIONS: These findings may help harm reduction organizations understand peer work and worker roles which may inform and promote equity in future harm reduction initiatives that include people with living and lived experience of substance use.
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Reducción del Daño , Trastornos Relacionados con Sustancias , Colombia Británica , Humanos , Grupo ParitarioRESUMEN
AIM: Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence. METHODS: A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants. RESULTS: Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6--12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants' liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms. CONCLUSION: MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.
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Consumo de Bebidas Alcohólicas/prevención & control , Alcoholismo/rehabilitación , Reducción del Daño , Evaluación de Programas y Proyectos de Salud , Adulto , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/tendencias , Alcoholismo/epidemiología , Canadá/epidemiología , Estudios de Casos y Controles , Ciudades/epidemiología , Etanol/administración & dosificación , Femenino , Vivienda , Humanos , Pruebas de Función Hepática , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Apoyo SocialRESUMEN
In this study, we examine the qualitative accounts of people who use drugs engaged in 'peer' work in harm reduction settings across British Columbia, Canada. We found peer work was precarious, characterized by nonstandard or casual work arrangements, high job instability and insecurity, insufficient wages, and limited social benefits. Participants were reluctant to exercise their rights or negotiate work conditions, such as higher wages or more consistent work, out of fear of job loss. However, the flexibility of peer work was beneficial for some in that it worked within their life circumstances and provided a low-barrier entry into the labor market. If inequities in peer work are perpetuated, unrecognized and unaddressed, precarious work conditions may continue to undermine the potential benefits of harm reduction work for organizations, peer workers and the people to whom they engage with and support. This study adds people who use drugs to the many social groups that are impacted by precarious work conditions globally.
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Reducción del Daño , Preparaciones Farmacéuticas , Colombia Británica , Humanos , Grupo Paritario , Investigación CualitativaRESUMEN
BACKGROUND: The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA). METHODS: We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs. RESULTS: Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing. CONCLUSIONS: In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.
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Alcoholismo/rehabilitación , Reducción del Daño , Personas con Mala Vivienda , Adulto , Anciano , Alcoholismo/psicología , Actitud Frente a la Salud , Canadá , Femenino , Personas Imposibilitadas/psicología , Humanos , Masculino , Programas Controlados de Atención en Salud , Persona de Mediana Edad , Pobreza , Apoyo Social , EstereotipoRESUMEN
BACKGROUND: Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL. METHODS: Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently. RESULTS: Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers. CONCLUSIONS: Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.
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Accesibilidad a los Servicios de Salud/normas , Cuidado Terminal/estadística & datos numéricos , Canadá , Utilización de Instalaciones y Servicios , Disparidades en Atención de Salud/estadística & datos numéricos , Personas con Mala Vivienda/estadística & datos numéricos , Humanos , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Factores de Riesgo , Administración de la Seguridad , Servicio Social/estadística & datos numéricos , Estereotipo , Trastornos Relacionados con Sustancias/psicología , Sobrevivientes/estadística & datos numéricos , Cuidado Terminal/normas , Poblaciones VulnerablesRESUMEN
The ability to colonize the chicken gut was determined for 17 Campylobacter jejuni strains of human and bovine origin. The level of colonization varied according to the strain used for experimental infection. Two Campylobacter isolates from patients suffering from gastroenteritis were found in the group of non-colonizing strains, suggesting that other reservoirs as poultry are also important sources of human Campylobacter infections. Bovine Campylobacter isolates can also effective colonize the chicken intestine and may be a source for poultry infection. The invasion ability of the strains as determined in the cell culture model using Caco-2 cells correlates with their colonization capacity in the chicken gut. The genomic and phenotypic stability of the selected strains were evaluated by analysis of their pulsed-field gel electrophoresis (PFGE) patterns, flaA-typing and in vitro determination of motility, adhesion and invasion abilities after colonizing chickens for up to 21 days. Changes were identified in flaA-types of six isolates and three isolates from chicken showed different patterns by PFGE using SmaI or KpnI as restriction enzymes. One isolate showed phenotypic differences after in vivo passage which were seen in enhancement of adherence to eukaryotic cells, decrease of motility and changes in morphology. These phenotypic changes were not associated with the observed genomic instabilities.
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Infecciones por Campylobacter/microbiología , Infecciones por Campylobacter/veterinaria , Campylobacter jejuni/fisiología , Pollos , Enfermedades Intestinales/microbiología , Enfermedades Intestinales/veterinaria , Enfermedades de las Aves de Corral/microbiología , Animales , Adhesión Bacteriana , Células CACO-2 , Campylobacter jejuni/genética , Campylobacter jejuni/crecimiento & desarrollo , Campylobacter jejuni/patogenicidad , Bovinos , Movimiento Celular/inmunología , ADN Bacteriano/genética , Electroforesis en Gel de Campo Pulsado/veterinaria , Humanos , Microscopía Electrónica de Transmisión/veterinaria , Reacción en Cadena de la Polimerasa/veterinaria , Polimorfismo de Longitud del Fragmento de Restricción , Distribución Aleatoria , Organismos Libres de Patógenos Específicos , Factores de Virulencia/genéticaRESUMEN
Reactive astrocytosis is a well-documented feature of HIV encephalitis (HIVE), but it is unclear whether restricted infection of astrocytes contributes to this phenomenon. In addition, the part played by reactive and/or infected astrocytes in AIDS-related dementia is not fully understood. In this study of patients at different stages of the human immunodeficiency virus (HIV) infection, who had been treated at most with one antiretroviral drug, reactive astrocytes were identified by immunopositivity for glial fibrillary acidic protein (GFAP) and infected astrocytes by positivity for HIV Nef protein. Results were compared for drug-using AIDS patients with (n=9) and without (n=7) HIVE, for presymptomatic HIV-positive drug users (n=12) and for control HIV-negative subjects (n=20), including a group who used drugs (n=10). GFAP-reactive astrocytes in both grey and white matter were significantly more numerous in HIVE subjects than in each of the other groups but did not correlate with viral load. Nef-positive astrocytes were confined to HIVE cases and to white matter, but were numerous in only one subject who was treatment-naive. Nef-positive microglia were identified in all HIVE cases and in occasional AIDS and presymptomatic subjects who did not have HIVE. The results suggest that astrocytes may form an additional viral reservoir in late HIV infection and may contribute to HIVE. However, the number of GFAP-positive astrocytes was neither increased in pre-AIDS nor in drug abuse, in contrast with microglia which we have shown previously to be up-regulated in both states.
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Complejo SIDA Demencia/patología , Astrocitos/química , Astrocitos/virología , Productos del Gen nef/análisis , Proteína Ácida Fibrilar de la Glía/análisis , Complejo SIDA Demencia/complicaciones , Complejo SIDA Demencia/metabolismo , Adulto , Astrocitos/patología , Recuento de Células , Trastornos del Conocimiento/metabolismo , Trastornos del Conocimiento/patología , Trastornos del Conocimiento/virología , Femenino , Gliosis/metabolismo , Gliosis/patología , Gliosis/virología , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Provirus , Trastornos Relacionados con Sustancias/complicaciones , Trastornos Relacionados con Sustancias/patología , Carga Viral , Productos del Gen nef del Virus de la Inmunodeficiencia HumanaRESUMEN
In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.
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Ética en Enfermería , Liderazgo , Investigación Metodológica en Enfermería , Calidad de la Atención de Salud , HumanosRESUMEN
Operation Fascination is an educational program about the perioperative experience targeted at the school-age community. The goals are to help children gain a better understanding of the perioperative process by incorporating it in the school curriculum and extracommunity curricula and to make the perioperative nurse more aware of school-age children's misconceptions. A literature search showed that little has been written about perioperative education of school-age children outside the health care institution. Therefore, this article shares the development and initiation of Operation Fascination as well as describes the importance and benefits of offering this type of program to the community.
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Niño Hospitalizado/psicología , Educación del Paciente como Asunto , Cuidados Preoperatorios , Niño , Humanos , Enfermería PosanestésicaRESUMEN
Golden hamsters raised at 22 degrees C were adapted in the early summer for 3 weeks to either 28 degrees C or 5 degrees C. To achieve profound changes the photoperiod was also shortened from 14 h to 11 h during adaptation to cold. During the investigation body weight, food consumption, water intake, urine production, and osmolality, as well as secreted amounts of noradrenaline (NA) and dopamine (DA), were recorded in each animal before, during, and after the adaptation period. In another group of golden hamsters the brains were processed for immunocytochemical detection of arginine-vasopressin (AVP) and corticotropin releasing factor (CRF) in the third week of adaptation to a cold or warm environment. In warm-adapted animals food and water consumption and urine production remained unchanged or were only slightly reduced. NA and DA secretion were reduced by 50%. The AVP-immunoreactivity reflected an anti-diuretic state in these animals. In fibers influencing the adrenal axis, AVP-immunoreactivity was weak compared to CRF fibers. Food and water consumption, urine production, and DA secretion increased two-fold during cold adaptation. Daily secreted amounts of NA increased nine-fold. AVP-immunoreactivity was weak in projections to the neurohypophysis. Fibers influencing the adrenal axis, however, displayed strong AVP-immunoreactivity in comparison to that of CRF. The immunocytochemically determined patterns of AVP and CRF distribution indicated an activation of the osmoregulative axis in the warm-adapted animals and of the adrenal axis in the cold-adapted golden hamsters.