A qualitative study of fourteen African countries' nursing workforce and labour market.

AIM: The aim of this study was to describe factors affecting nursing education and labour markets in countries in East, Central, and Southern Africa, and critical areas for investment. BACKGROUND: An understanding about the relationship between the supply of nurses (determined by types of educational programmes, and the quantity and quality of nurse graduates), and workforce demand is critical to health policy development. METHODS: Six focus groups and 14 key informant interviews with nursing leaders and experts were conducted. Participants included government chief nursing officers, registrars of regulatory bodies, association leaders and heads of nursing education. The data were transcribed, coded and analysed using inductive techniques. FINDINGS: Participants discussed challenges and strengths of nursing education, school and regulatory infrastructure, financing mechanisms for the nursing workforce, the state of nursing jobs and scope of nursing practice. CONCLUSION: Strengthened regulations and leadership are needed to improve investment in nursing, the quality of nursing education, and working conditions and to promote the achievement of better health outcomes. IMPLICATIONS FOR NURSING POLICY: Clarifying scope of practice for nurses in the health sector and creating competency-based requirements is important. Governments should establish positions that align with updated competencies and provide fair and safe working conditions. The current and ongoing investment case for nursing requires improved data systems and a commitment to use labour market data for decision-making.

Prevalence, correlates, and self-management of HIV-related depressive symptoms.

Depressive symptoms are highly prevalent yet undertreated in people living with HIV/AIDS (PLHAs). As part of a larger study of symptom self-management (N=1217), this study examined the prevalence, correlates, and characteristics (intensity, distress, and impact) of depressive symptoms, and the self-care strategies used to manage those symptoms in PLHAs in five countries. The proportion of respondents from each country in the total sample reporting depressive symptoms in the past week varied and included Colombia (44%), Norway (66%), Puerto Rico (57%), Taiwan (35%), and the USA (56%). Fifty-four percent (n=655) of the total sample reported experiencing depressive symptoms in the past week, with a mean of 4.1 (SD 2.1) days of depression. Mean depression intensity 5.4 (SD 2.7), distressfulness 5.5 (SD 2.86), and impact 5.5 (SD 3.0) were rated on a 1-10 scale. The mean Center for Epidemiologic Studies Depression Scale score for those reporting depressive symptoms was 27 (SD 11; range 3-58), and varied significantly by country. Respondents identified 19 self-care behaviors for depressive symptoms, which fell into six categories: complementary therapies, talking to others, distraction techniques, physical activity, medications, and denial/avoidant coping. The most frequently used strategies varied by country. In the US sample, 33% of the variance in depressive symptoms was predicted by the combination of education, HIV symptoms, psychological and social support, and perceived consequences of HIV disease.

HIV illness representation as a predictor of self-care management and health outcomes: a multi-site, cross-cultural study.

Research has shown that the perceptions that form the cognitive representation of an illness (illness representation) are fundamental to how persons cope with illness. This study examined the relationship of illness representation of HIV with self-care behavior and health outcomes. Data were collected at 16 sites in the United States, Taiwan, Norway, Puerto Rico and Colombia via survey. HIV seropositive participants (n = 1,217, 31% female, 38% African-American/Black, 10% Asian/Pacific Islander and 26% White/Anglo) completed measures of illness representation based on the commonly accepted five-component structure: identity, time-line, consequences, cause, and cure/controllability (Weinman et al. 1996, Psychology and Health, 11, 431-445). Linear regression analyses were conducted to investigate relationships among illness representation, self-care behaviors and quality-of-life outcomes. Components of illness representation were associated with self-care and health outcomes, indicating that the cognitive representation of HIV has consequences for effective illness management. For example, perception that there is little that can be done to control HIV was significantly associated with fewer and less effective self-care activities (F = 12.86, P < .001) and poorer health function in the domain of quality-of-life (F = 13.89, P < .001). The concept of illness representation provides a useful framework for understanding HIV symptom management and may be useful in directing development of effective patient-centered interventions.

Stigma, HIV and AIDS: an exploration and elaboration of a stigma trajectory.

Stigma is a social construction which dramatically affects the life experiences of the individuals infected with the human immunodeficiency virus (HIV) and their partners, family and friends. While it has been generally recognized that the nature of stigma varies across illnesses, it has usually not been considered as changing and emerging over the course of a single illness. In this paper, HIV/AIDS is analyzed in terms of a stigma trajectory. The primary purpose is to conceptualize how individuals with HIV/AIDS experience stigma and to demonstrate how these experiences are affected by changes in the biophysical dimensions of HIV/AIDS. Four phases of the HIV/AIDS stigma trajectory are depicted: (1) at risk: pre-stigma and the worried well; (2) diagnosis: confronting an altered identity; (3) latent: living between illness and health; and (4) manifest: passage to social and physical death. The essential processes through which individuals personalize the illness, dilemmas encountered in interpersonal relations, strategies that are used to avoid or minimize HIV-related stigma, and subcultural networks and ideologies that are drawn upon to construct, avow, and adapt to an HIV identity are considered across the stigma trajectory.

The structure of emotions during acute myocardial infarction: a model of coping.

The present state of medical care for heart attacks, or acute myocardial infarction (AMI), clearly indicates that rapidly and expeditiously seeking definitive medical care will reduce morbidity and prevent mortality. Despite the clearly established advantages of rapid AMI treatment, the time from the onset of acute symptoms of AMI to definitive medical care is often prolonged and individuals with a prior history of AMI and/or coronary artery disease (CAD) extend care-seeking. Behaviors and actions surrounding acute care-seeking are often fraught with complex social, psychological and emotional processes. The purpose of the present paper is to bring together a theoretical and an applied understanding of the interval of time from acute symptom onset to definitive medical care during AMI; and to understand the role of emotions in the care-seeking process. This task is especially important among individuals with a prior history of AMI and/or CHD. These individuals can be seen as experiencing a "spectrum of posttraumatic disturbances", ranging from anxiety to posttraumatic stress disorder and alexithymia. These disturbances contribute to extended care-seeking thereby placing the individuals at greater risk for AMI and sudden cardiac death. Effective intervention requires three elements. First, knowledge is necessary so that individual and lay others can correctly label symptoms and signs of an AMI. Second, it is necessary to provide feasible behaviors that individuals and lay others can use to access definitive medical care. Third, and perhaps most importantly, it is necessary to provide understanding of and skills to cope with the emotional arousal surrounding both the primary traumatic experience of symptoms and signs, potential secondary traumatic consequences of AMI care-seeking and tertiary trauma from the long-term consequences of CHD.

The impact of livestock-farming on welsh streams: the development and testing of a rapid biological method for use in the assessment and control of organic pollution from farms.

Organic wastes from intensive agriculture are a major cause of surface-water pollution in Great Britain. There are a large number of possible sources for such pollution, and there is a need to target the efforts of pollution-control authorities to the worst-affected parts of catchments. This paper describes the development of a rapid method for the identification of polluted streams based upon the macro-invertebrate fauna. An indicator key was developed by TWINSPAN classification of data from benthic sampling at 55 sites in West Wales. The key requires assessment of the abundance of four macroinvertebrate taxa and of the extent of 'sewage-fungus' growth, all of which can be determined by examination in the field. The key can separate sites into three groups representing different levels of pollution impact as indicated by differences in biotic indices and chemical data. The system was tested successfully at a further 146 sites in West Wales resulting in the notification of 49 farms to the pollution-control authorities. Non-biologists were able to use the key efficiently after a short period of training. A further test involving 51 sites in Devon indicated that the technique may be adaptable to other parts of Great Britain. It is envisaged that indicator systems designed to suit local fauna may have a major role in a pro-active strategy developed to combat pollution from farms because they have potential advantages over more complex biological methods currently in use.

Responding to symptoms and signs of acute myocardial infarction--how do you educate the public?: a social-psychologic approach to intervention.

In an era of highly time-dependent therapies for acute myocardial infarction-namely thrombolytic therapy and cardiopulmonary resuscitation-it is imperative that public education programs facilitate expeditious care-seeking. However, community intervention studies to reduce the interval of time-from the onset of an acute myocardial infarction to arrival at a hospital emergency department-have shown ambiguous results. To understand and reduce this time interval, a theoretic model is proposed that draws from self-regulation theory. The combined model focuses on three issues: first, information for systematic sign-and-symptom recognition and labeling; second, behavioral information as to what to do in the event of an acute myocardial infarction; and third, information on how to control affective and emotional responses that may interfere with effective coping. Seven recommendations are made for guiding community intervention with use of the proposed model.

Patient appraisal of mandarin orange didanosine: implications for adherence and well-being.

Didanosine (Videx, ddI) has been shown to be an effective agent in the treatment of HIV disease. However, patients have had difficulties adhering to didanosine preparations due to taste aversion and/or associated nausea. The efficacy of didanosine may, therefore, be compromised. This is of concern to clinicians who seek to promote patient adherence to medication regimes and to foster the quality of patient well-being. In this study, focus groups were used to gather exploratory data about patient (n = 15) response to the new mandarin orange didanosine preparation. Data were audiotaped, transcribed verbatim, and systematically analyzed by the investigators using inductive techniques. Findings provide information regarding client evaluation of the new didanosine preparation and patterns of usage. Although clients generally find the mandarin orange preparation more tolerable, they describe engaging in numerous strategies aimed at attenuating what they experience as the inconvenience of taking the medication. Mental tricks, systematic restructuring of daily routines and environment, and dietary schemes were among the strategies devised by patients through trial and error to self-promote their adherence.

Uncertainty in illness across the HIV/AIDS trajectory.

Uncertainty is a chronic and pervasive source of psychological distress for persons living with HIV. Numerous sources of heightened uncertainty, including complex changing treatments, ambiguous symptom patterns, and fears of ostracizing social response, play a critical role in the experience of HIV-positive persons and are linked with negative perceptions of quality of life and poor psychological adjustment. Currently, research on uncertainty in HIV fails to explicate the uncertainty experience over time. Because the uncertainty of HIV varies over the course of the illness, an explicit consideration of the sources of uncertainty over the HIV illness trajectory is needed to forecast the informational and stress management needs of persons facing uncertainty about HIV illness. A biopsychosocial model developed to characterize the HIV stigma trajectory provides a useful framework modified to depict uncertainty across the HIV illness experience. Uncertainty in four phases of the HIV illness trajectory are differentiated: (a) at risk, (b) diagnosis, (c) latent, and (d) manifest.

Initiatives to promote adherence in HIV-infected patients.

Potent antiretroviral drug regimens have provided new opportunities to treat patients with HIV disease effectively. Yet, the true potential of the combination therapies can be realized only if people living with HIV adhere to the difficult treatment regimens. Even brief intervals of suboptimal dosing may allow activation of viral replication and development of drug-resistant strains. Maximizing adherence and achieving the full potential of the antiretroviral therapies in practice settings demand multidimensional initiatives that address complex behavioral and biomedical issues.

Unhealthy behaviours for self-management of HIV-related peripheral neuropathy.

The prevalence of peripheral neuropathy is frequent in HIV disease and is often associated with antiretroviral therapy. Unhealthy behaviours, particularly substance-use behaviours, are utilized by many HIV-positive individuals to manage neuropathic symptoms. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of unhealthy behaviours to self-manage peripheral neuropathy in HIV disease. Sociodemographic and disease-related correlates and unhealthy behaviours were examined in a convenience sample of 1,217 respondents who were recruited from data collection sites in several US cities, Puerto Rico, Colombia, and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified a variety of unhealthy self-care behaviours including injection drug use, oral drug use, smoking cigarettes and alcohol ingestion. Specific unhealthy behaviours that participants reported to alleviate peripheral neuropathy included use of marijuana (n=67), smoking cigarettes (n=139), drinking alcohol (n=81) and street drugs (n=30). A subset of those individuals (n=160), who identified high levels of neuropathy (greater than five on a scale of 1-10), indicated significantly higher use of amphetamines and injection drug use in addition to alcohol use and cigarette smoking. For participants from Norway, substance use (using alcohol: 56%) was one of the most frequent self-management strategies. Implications for clinical practice include assessment and education of persons with HIV for self-care management of the complex symptom of peripheral neuropathy.

Symptom management and self-care for peripheral neuropathy in HIV/AIDS.

Peripheral neuropathy is the most common neurological complication in HIV and is often associated with antiretroviral therapy. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of peripheral neuropathy in HIV disease, sociodemographic and disease-related correlates and self-care strategies. A convenience sample of 1,217 respondents was recruited from data collection sites in several US cities, Puerto Rico, Colombia and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified 20 self-care behaviors including complementary therapies, use of medications, exercise and rest and/or elevation of extremities. Ratings of frequency and effectiveness were also included. An activities checklist summarized into five categories of self-care behaviors including activities/thoughts, exercise, medications, complementary therapies and substance was used to determine self-care behaviors. Taking a hot bath was the most frequent strategy used by those with peripheral neuropathy (n=292) and received the highest overall rating of effectiveness of any self-management strategies included in this study at 8.1 (scale 1-10). Other self-care strategies to manage this symptom included: staying off the feet (n=258), rubbing the feet with cream (n=177), elevating the feet (n=236), walking (n=262), prescribed anti-epileptic agent (n=80), prescribed analgesics (n=84), over-the-counter medications (n=123), vitamin B (n=122), calcium supplements (n=72), magnesium (n=48), massage (n=156), acupuncture (n=43), reflexology (n=23) and meditation (n=80). Several behaviors that are often deemed unhealthy were included among the strategies reported to alleviate peripheral neuropathy including use of marijuana (n=67), cigarette smoking (n=139), drinking alcohol (n=81) and street drugs (n=30).

Balancing disfigurement and fear of disease progression: Patient perceptions of HIV body fat redistribution.

This study was conducted to identify and describe the perceived morphologic changes of body fat redistribution and related distress among persons taking combination antiretroviral therapy. Six focus group interviews were conducted in four different US cities with men and women (n = 58) who reported antiretroviral-related symptoms of body fat loss and/or gain. Interview data were audiotaped, transcribed verbatim and systematically analysed using inductive techniques. Physical discomfort and impairment and psychological and social distress were reported across sex, sexual orientation and geographic subgroups. While participants acknowledged that antiretroviral drugs were keeping them alive, there was tension between the desire for life-sustaining treatment and optimal quality of life. Some participants engaged in harmful heath behaviours in an attempt to control bodily changes (e.g. non-adherence to antiretroviral regimen). Participants feared that fat loss represented disease progression and worried that visible changes would lead to unintentional disclosure of their HIV status. Although a potential source of support, healthcare providers were commonly perceived as ignoring and, in so doing, discrediting patient distress. Participants recognised the limitations of current lipodystrophy treatment options, yet a cure for the syndrome seemed less important to them in the short term than simply being listened to and the powerful, but oblique sources of distress addressed.

The problem of antiretroviral adherence: a self-regulatory model for intervention.

Controlled trials that determine which interventions can significantly improve adherence to combination antiretroviral regimens are urgently needed. Rates of adherence to the regimens are often sub-optimal, and while a variety of factors that are predictive or associated with antiretroviral adherence have been identified, few research findings are reported of interventions that effectively promote adherence and improve health outcomes. Further, the mechanisms by which interventions promote antiretroviral adherence are not well understood. Maximizing adherence and achieving the full potential of the antiretroviral therapies demand multidimensional initiatives that address complex behavioural and biomedical issues. A model drawn from self-regulation theory and empirical data to explain antiretroviral medication adherence is proposed.

HIV informal caregiving: emergent conflict and growth.

Findings are reported from a prospective study of 20 persons on the experience of providing informal care to partners or family members with HIV syndrome. In-depth, focused interviews were completed. Data were initially coded using an inductive technique and thematically analyzed. The informal care providers were found to engage in a variety of interacting, and often conflicting, psychosocial and instrumental processes that occurred over three emergent phases: (a) transitions to care, (b) living the burden, and (c) facing the void. Although the care providers struggled with various sources of uncertainty and distress, when periods of equanimity were realized, they experienced a heightened sense of coherence and personal growth.

Meta-analysis for descriptive research.

Although nurses have begun to use meta-analysis, a review of the nursing literature demonstrates that its use has not been maximized. Meta-analysis can be employed to synthesize descriptive as well as experimental research, yet attention in nursing has focused almost exclusively on meta-analysis techniques for, and meta-analytic studies of, experimental research. Furthermore, nursing literature has emphasized use of the effect size index (d) rather than the correlation index (r); the latter may, in some cases, be the more suitable metric, particularly with meta-analysis of correlational studies. An argument is made for the value of meta-analysis as a technique for integrating descriptive research, and an overview of different meta-analytic approaches to data analysis using the correlational index with descriptive research is provided.

Home health care services for AIDS patients: one community's response.

The AIDS epidemic has challenged communities to develop and mobilize care networks for persons infected with the human immunodeficiency virus (HIV). A major part of that mobilization has been a push toward community- and home-based services. The movement of HIV care to the home/community setting is occurring, however, without investigation of either the problems that this change engenders for agencies providing care or the agencies' responses to these problems. This article from one health care market suggests that home care agencies may not be well positioned to meet the cyclical needs of HIV patients, that care is becoming increasingly fragmented with multiple agencies seeking to patch together a program of comprehensive services, and that agency policies may be limiting the numbers of community-based HIV patients eligible for home care.