Through the Lens of Postcolonial Theory: Establishing Global North-South Partnerships.

AIM: This study used postcolonial theory as a critical lens to examine the factors that supported or hindered equitable partnership formation within an innovative international service-learning (ISL) program in nursing education. BACKGROUND: As ISL programs proliferate, ethical concerns have arisen as minimal attention has been given to both the host and visiting partners' experience and perceptions and how these impact partnership development and outcomes. METHOD: A hybrid intrinsic, instrumental, single embedded case study design, including observations, interviews (n = 70), and document analysis, was used to analyze in depth varied partnerships within a US-Kenyan ISL program. RESULTS: Central themes of dispelling assumptions, making connections, revealing privilege, and sharing power emerged and formed a theoretical model, Establishing and Strengthening Partnerships. CONCLUSION: Attention needs to be given to preconceived assumptions, imbalances in privilege, and issues surrounding power and decision-making for equitable, impactful, partnership development. Leadership philosophy, style, and approach make a difference.

Cost-effectiveness of the non-laboratory based Framingham algorithm in primary prevention of cardiovascular disease: A simulated analysis of a cohort of African American adults.

The non-lab Framingham algorithm, which substitute body mass index for lipids in the laboratory based (lab-based) Framingham algorithm, has been validated among African Americans (AAs). However, its cost-effectiveness and economic tradeoffs have not been evaluated. This study examines the incremental cost-effectiveness ratio (ICER) of two cardiovascular disease (CVD) prevention programs guided by the non-lab versus lab-based Framingham algorithm. We simulated the World Health Organization CVD prevention guidelines on a cohort of 2690 AA participants in the Atherosclerosis Risk in Communities (ARIC) cohort. Costs were estimated using Medicare fee schedules (diagnostic tests, drugs & visits), Bureau of Labor Statistics (RN wages), and estimates for managing incident CVD events. Outcomes were assumed to be true positive cases detected at a data driven treatment threshold. Both algorithms had the best balance of sensitivity/specificity at the moderate risk threshold (>10% risk). Over 12years, 82% and 77% of 401 incident CVD events were accurately predicted via the non-lab and lab-based Framingham algorithms, respectively. There were 20 fewer false negative cases in the non-lab approach translating into over $900,000 in savings over 12years. The ICER was -$57,153 for every extra CVD event prevented when using the non-lab algorithm. The approach guided by the non-lab Framingham strategy dominated the lab-based approach with respect to both costs and predictive ability. Consequently, the non-lab Framingham algorithm could potentially provide a highly effective screening tool at lower cost to address the high burden of CVD especially among AA and in resource-constrained settings where lab tests are unavailable.

Mobile health-delivered narrative intervention to increase cervical cancer screening among Malawian women living with HIV: A pilot randomized controlled trial.

Objective: This study aimed to develop and evaluate a mobile health (mHealth)-delivered, theory-guided, culturally tailored storytelling narrative (STN) intervention to increase cervical cancer screening among Malawian women living with human immunodeficiency virus (HIV). Methods: This study involved two phases: Phase 1: development of a theory-guided and culturally adapted STN intervention and Phase 2: a pilot randomized controlled trial was conducted. Participants were randomly assigned to one of three arms: Arm 1: tablet-based video (mHealth) with STN (n = 60); Arm 2: mHealth with a video of nonnarrative educational materials (n = 59); and Arm 3: control group with only reading nonnarrative educational materials in person (n = 60). Cervical cancer screening was measured using visual inspection with acetic acid (VIA) uptakes by self-report and health passport record review at 2 and 6 months after intervention. Results: Both arms 1 and 2 had nearly twice the rate of VIA uptakes than those in Arm 3 (51.0% and 50.0%, respectively, vs. 35.0%, P = 0.01) at 2 months follow-up, but there were no differences among groups from 2- to 6-month follow-ups. All groups demonstrated significant improvement of knowledge about risk factors, intention, and VIA uptakes. Conclusions: The findings demonstrate the preliminary effectiveness of the intervention on cervical cancer screening behavior and the feasibility of the study regarding recruitment, retention, treatment fidelity, and acceptability of the single 30-min session. The feasibility and the preliminary results of the effectiveness of the proposed study indicate scaling up the STN intervention to a larger population of women to increase cervical cancer screening uptake to prevent deaths due to cervical cancer in Malawi.

Evaluation of the performance of existing non-laboratory based cardiovascular risk assessment algorithms.

BACKGROUND: The high burden and rising incidence of cardiovascular disease (CVD) in resource constrained countries necessitates implementation of robust and pragmatic primary and secondary prevention strategies. Many current CVD management guidelines recommend absolute cardiovascular (CV) risk assessment as a clinically sound guide to preventive and treatment strategies. Development of non-laboratory based cardiovascular risk assessment algorithms enable absolute risk assessment in resource constrained countries.The objective of this review is to evaluate the performance of existing non-laboratory based CV risk assessment algorithms using the benchmarks for clinically useful CV risk assessment algorithms outlined by Cooney and colleagues. METHODS: A literature search to identify non-laboratory based risk prediction algorithms was performed in MEDLINE, CINAHL, Ovid Premier Nursing Journals Plus, and PubMed databases. The identified algorithms were evaluated using the benchmarks for clinically useful cardiovascular risk assessment algorithms outlined by Cooney and colleagues. RESULTS: Five non-laboratory based CV risk assessment algorithms were identified. The Gaziano and Framingham algorithms met the criteria for appropriateness of statistical methods used to derive the algorithms and endpoints. The Swedish Consultation, Framingham and Gaziano algorithms demonstrated good discrimination in derivation datasets. Only the Gaziano algorithm was externally validated where it had optimal discrimination. The Gaziano and WHO algorithms had chart formats which made them simple and user friendly for clinical application. CONCLUSION: Both the Gaziano and Framingham non-laboratory based algorithms met most of the criteria outlined by Cooney and colleagues. External validation of the algorithms in diverse samples is needed to ascertain their performance and applicability to different populations and to enhance clinicians' confidence in them.

Association of Parental Cardiovascular Health With Disability-Adjusted Life Years in the Offspring: Results From the Framingham Heart Study.

BACKGROUND: Disability-adjusted life years (DALYs) are used to evaluate the relative burden of diseases in populations to help set prevention or treatment priorities. The impact of parental cardiovascular health (CVH) on healthy life years lost from cardiovascular disease (CVD) in adult offspring is unknown. We compared parent-offspring CVD DALYs trends over the life course and examined the association of parental CVH with offspring CVD DALYs. METHODS: Using data from the Framingham Heart Study, 4814 offspring-mother-father trios were matched for age at selected baseline exams. CVH score was computed from the number of CVH metrics attained at recommended levels: poor (0-2), intermediate (3-4), and ideal (5-7). CVD DALYs were defined as the sum of years of life lost and years lived with CVD. Age-sex-standardized life expectancy and disability weights were derived from the actuarial life tables and Global Burden of Disease study, respectively. Multivariable-adjusted linear regression was used to investigate the association of parental CVH with offspring CVD DALYs. RESULTS: Over an equal 47-year follow-up, parents lost nearly twice the number of CVD DALYs compared to their offspring (23 234 versus 12 217). However, age-adjusted CVD DALYs were higher at younger ages and similar along the life course for parents and offspring. One-unit increase in parental CVH was associated with 5 healthy life months saved in offspring. Offspring of mothers with ideal versus poor CVH had 3 healthy life years saved (ß=-3.0 DALYs [95% CI, -5.6 to -0.3]). No statistically significant association was found between paternal CVH categories and offspring CVD DALYs. CONCLUSIONS: Higher maternal and paternal CVH were associated with increased healthy life years in offspring; however, the association was strongest between mothers and offspring. Investment in CVH promotion along the life course has the potential to reduce the burden of CVD in the current and future generation of adults.

Parental cardiovascular health predicts time to onset of cardiovascular disease in offspring.

BACKGROUND: Cardiovascular disease (CVD) risk factors are transmitted from parents to children. We prospectively examined the association between parental cardiovascular health (CVH) and time to onset of CVD in the offspring. METHODS AND RESULTS: The study consisted of a total of 5967 offspring-mother-father trios derived from the Framingham Heart Study. Cardiovascular health score was defined using the seven American Heart Association's CVH metrics attained at ideal levels: poor (0-2), intermediate (3-4), and ideal CVH (5-7). Multivariable-adjusted Cox proportional hazards regression models, Kaplan-Meier plots, and Irwin's restricted mean were used to examine the association and sex-specific differences between parental CVH and offspring's CVD-free survival. In a total of 71 974 person-years of follow-up among the offspring, 718 incident CVD events occurred. The overall CVD incidence rate was 10 per 1000 person-years [95% confidence interval (CI) 9.3-10.7]. Offspring of mothers with ideal CVH lived 9 more years free of CVD than offspring of mothers with poor CVH (P < 0.001). Maternal poor CVH was associated with twice as high hazard of early onset of CVD compared with maternal ideal CVH (adjusted Hazard Ratio 2.09, 95% CI 1.50-2.92). No statistically significant association was observed in the hazards of CVD-free survival by paternal CVH categories. CONCLUSIONS: We found that offspring of parents with ideal CVH had a greater CVD-free survival. Maternal CVH was a more robust predictor of offspring's CVD-free survival than paternal CVH, underscoring the need for clinical and policy interventions that involve mothers to break the intergenerational cycle of CVD-related morbidity and mortality.

Partnering to Build Human Resources for Health Capacity in Africa: A Descriptive Review of the Global Health Service Partnership's Innovative Model for Health Professional Education and Training From 2013-2018.

Several Sustainable Development Goals (SDGs) (3, 16, 17) point to the need to systematically address massive shortages of human resources for health (HRH), build capacity and leverage partnerships to reduce the burden of global illness. Addressing these complex needs remain challenging, as simple increases in absolute numbers of healthcare providers trained is insufficient; substantial investment into long-term high-quality training programs is needed, as are incentives to retain qualified professionals within local systems of care delivery. We describe a novel HRH initiative, the Global Health Service Partnership (GHSP), involving collaboration between the US government (President's Emergency Plan for AIDS Relief [PEPFAR], Peace Corps), 5 African countries, and a US-based non-profit, Seed Global Health. GHSP was formed to enlist US health professionals to assist in strengthening teaching and training capacity and focused on pre-and in-service medical and nursing education in Malawi, Tanzania, Uganda, Eswatini and Liberia. From 2013-2018, GHSP sent 186 US health professionals to 27 institutions in 5 countries, helping to train 16 280 unique trainees of all levels. Qualitative impacts included cultivating a supportive classroom learning environment, providing a pedagogical bridge to clinical service, and fostering a supportive clinical learning and practice environment through role modeling, mentorship and personalized learning at the bedside. GHSP represented a novel, multilateral, public-private collaboration to help address HRH needs in Africa. It offers a plausible, structured template for engagement and partnership in the field.

Lesbians' attitudes and beliefs regarding overweight and weight reduction.

AIM AND OBJECTIVE: This article presents data on attitudes and beliefs about overweight/weight reduction in lesbians. The project was developed to have information on which to base future culturally sensitive interventions to reduce cardiovascular risk in lesbians. BACKGROUND: Lesbians have been found to have high rates of obesity/overweight and to be more accepting of it. Researchers have hypothesised that this is attributed to different attitudes towards body weight and shape in lesbians than heterosexuals. Little is known about acceptable ways to intervene to decrease cardiovascular risk in lesbians in view of these attitudes. DESIGN: omen over 21 who self-identified as lesbian and reported one or more cardiovascular risk factors were recruited from medical providers and community resources. Twenty-five women participated in five focus groups that explored practices, attitudes and beliefs about cardiovascular risk and culturally acceptable strategies to reduce cardiovascular risk in lesbians. METHOD: Demographic and risk factor information was collected from focus group members by questionnaire. Focus groups were audiotaped and transcribed. Investigators reviewed the transcripts and identified, coded and categorised data to begin to identify emergent themes. RESULTS: Lesbian participants with risk factors for cardiovascular risk expressed concern about the health consequences of weight but want a focus on their general health rather than exclusively on the BMI. There is not homogeneity in attitudes and beliefs about weight and overweight among lesbians, and generational differences were found. Minority stress, anxiety and depression and homophobia were major factors in health behaviours and barriers to changing unhealthy behaviours. RELEVANCE TO CLINICAL PRACTICE: Lesbian participants with risk factors for cardiovascular disease were eager to be involved in individual and group culturally sensitive programs that focus on improved health and well being. Recommended interventions include lesbian specific multidimensional group interventions that could deal with the multiple factors involved in causing and maintaining the behaviours.

Endoscopic procedure with a modified Reiki intervention: a pilot study.

This pilot study examined the use of Reiki prior to colonoscopy to reduce anxiety and minimize intraprocedure medications compared with usual care. A prospective, nonblinded, partially randomized patient preference design was employed using 21 subjects undergoing colonoscopy for the first time. Symptoms of anxiety and pain were assessed using a Likert-type scale. Between-group differences were assessed using chi-square analyses and analysis of variance. There were no differences between the control (n = 10) and experimental (n = 11) groups on age (mean = 58 years, SD = 8.5) and gender (53% women). The experimental group had higher anxiety (4.5 vs. 2.6, p = .03) and pain (0.8 vs. 0.2, p = .42) scores prior to colonoscopy. The Reiki intervention reduced mean heart rate (-9 beats/minute), systolic blood pressure (-10 mmHg), diastolic blood pressure (-4 mmHg), and respirations (-3 breaths/minute). There were no between-group differences on intraprocedure medication use or postprocedure physiologic measures. Although the experimental group patients had more symptoms, they did not require additional pain medication during the procedure, suggesting that (1) anxious people may benefit from an adjunctive therapy; (2) anxiety and pain are decreased by Reiki therapy for patients undergoing colonoscopy, and (3) additional intraprocedure pain medication may not be needed for colonoscopy patients receiving Reiki therapy. This pilot study provided important insights in preparation for a rigorous, randomized, controlled clinical trial.

Temporal Trends and Familial Clustering of Ideal Cardiovascular Health in Parents and Offspring Over the Life Course: An Investigation Using The Framingham Heart Study.

Background Evidence suggests familial aggregation and intergenerational associations for individual cardiovascular health (CVH) metrics. Over a 53-year life course, we examined trends and association of CVH between parents and their offspring at similar mean ages. Methods and Results We conducted a series of cross-sectional analyses of the FHS (Framingham Heart Study). Parent-offspring pairs were assessed at exams where their mean age distributions were similar. Ideal CVH was defined using 5 CVH metrics: blood pressure (<120/<80 mm Hg), fasting blood glucose (<100 mg/dL), blood cholesterol (<200 mg/dL), body mass index (<25 kg/m2), and non-smoking. Joinpoint regression and Chi-squared test were used to assess linear trend; proportional-odds regression was used to examine the association between parents and offspring CVH. A total of 2637 parents were paired with 3119 biological offspring throughout 6 exam cycles. Similar patterns of declining ideal CVH with advancing age were observed in parents and offspring. Small proportions of parents (4%) and offspring (17%) achieved 5 CVH metrics at ideal levels (P-trend <0.001). Offspring of parents with poor CVH had more than twice the odds of having poor CVH (pooled odds ratio, 2.59; 95% CI, 1.98-3.40). Over time, elevated glucose levels and obesity doubled among the offspring and were the main drivers for declining ideal CVH trends. Conclusions Parental CVH was positively associated with offspring CVH. However, intergenerational CVH gains from declining smoking rates, cholesterol, and blood pressure were offset by rising offspring obesity and elevated glucose levels. This suggests an intergenerational phenotypic shift of risk factors and the need for a family-centered approach to cardiovascular care.

Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy.

Introduction: Eswatini, a small, largely rural country in Southern Africa, has a high burden of morbidity/mortality in the setting of a critical shortage of human resources for health. To help achieve universal access to healthcare across the lifespan, the advanced practice family nurse practitioner (FNP) role was proposed and is in the process of being implemented. Methods/Approach: The PEPPA framework (Participatory, Evidence-based, Patient focused Process for Advanced practice nursing) illustrates the steps in the process of developing and implementing the FNP role in a country. These steps include: determining the need for the role, deciding on a model of care, developing/implementing the curriculum, relevant policies, and scope of practice (SOP), and integrating the role into relevant nursing regulations and Ministry of Health (MOH) guidelines and documents. Outcomes: The assessment has been completed, a locally tailored competency-based FNP curriculum has been developed, revised, and implemented, the FNP SOP has been approved and MOH guidelines are being updated to reflect current evidence-based practice and to integrate the FNP role. Continuous cycles of improvement/revision were needed to adapt the curriculum and SOP to meet local needs. Clinical placements were challenging since this is a new health cadre, but most challenges were overcome and many resulted in important opportunities for interdisciplinary collaboration. Summary: Outcomes from this quality improvement initiative demonstrate that it is feasible to develop and implement a locally responsive, competency-based FNP program in a low resource setting and enroll students, despite time and financial constraints. Adapting the curriculum and SOP from western countries can provide a foundation for program development but revision to assure that the program is responsive to local context is then needed. There is general acceptance of the role among Eswatini communities and professional stakeholders with emphasis on the need for FNP graduates to be clinically competent and able to function independently. Policy work related to deploying new graduates is ongoing.

Gender differences in presenting and prodromal stroke symptoms.

BACKGROUND AND PURPOSE: Prompt recognition of stroke symptoms is critical to timely treatment and women have increased delay to treatment. Women may be more likely to present with atypical symptoms, but this hypothesis has not been extensively evaluated. METHODS: We examined gender differences in the prevalence of presenting and prodromal stroke symptoms among 1107 consecutive patients hospitalized with neurologist-confirmed acute ischemic stroke. Patient demographics, clinical variables, and stroke symptoms were abstracted from medical records by trained abstractors using standardized forms. Estimates were age-standardized to the age distribution of men and women combined. Presenting symptoms occurred within 24 hours of incident stroke admission; prodromal symptoms occurred >or=24 hours of admission. RESULTS: Women were significantly older (P<0.001), more likely to have cardioembolic stroke (P<0.01), and less likely to receive aspirin (P=0.014) or statins (P<0.001). Thirty-five percent of the sample (n=389) reported prodromal symptoms. Women were more likely to have >or=1 somatic prodromal and presenting symptoms (P=0.03; P=0.008), but did not differ from men on specific somatic symptoms. Women did not differ from men in classic presenting stroke symptoms (P=0.89). CONCLUSIONS: Women did not differ significantly in the prevalence of traditional stroke symptoms but were more likely to have somatic presenting and prodromal symptoms. We found no differences in specific prodromal symptoms, making it difficult to craft a public health message about gender differences in early warning signs of stroke. These results suggest that the focus of stroke prevention education for women should continue to emphasize traditional stroke risk factors.

The power of partnership: addressing cancer health disparities through an academic-service partnership.

Partnerships between universities and healthcare organizations help foster interdisciplinary collaboration and can yield programs to address pressing needs in both sectors. In spite of these benefits, such partnerships remain more the exception than the norm. This article describes a partnership between a comprehensive cancer center and a university-based college of nursing and health sciences that serves a diverse student population. With the support of U-56 funding, the 2 organizations collaborated to develop a new, 87-credit BS-to-PhD in Nursing program and to enhance the university's traditional PhD in nursing program. Both PhD programs prepare nurses for careers in teaching, health policy, and research related to cancer health disparities. In addition to an innovative curriculum, the programs include a mentorship that leverages the research expertise and scholarly resources of both organizations and a community outreach component that gives students experience in planning and implementing educational and risk-reduction programs addressing cancer health disparities.

Validity of hemoglobin A1c for diagnosing diabetes among people with and without HIV in Uganda.

Sub-Saharan Africa (SSA) is facing a growing co-epidemic of chronic HIV infection and diabetes. Hemoglobin A1c (A1c) may underestimate glycemia among people living with HIV (PLWH). We estimated the validity of A1c to diagnose diabetes among PLWH and HIV-uninfected persons in rural Uganda. Data were derived from a cohort of PLWH and age- and gender-matched HIV-uninfected comparators. We compared A1c to fasting blood glucose (FBG) using Pearson correlations, regression models, and estimated the sensitivity and specificity of A1c for detecting diabetes with FBG ≥126 mg/dL as reference standard. Approximately half (48%) of the 212 participants were female, mean age of 51.7 years (SD = 7.0) at enrollment. All PLWH (n = 118) were on antiretroviral therapy for a median of 7.5 years with mean CD4 cell count of 442 cells/µL. Mean FBG (89.7 mg/dL) and A1c (5.6%) were not different between PLWH and HIV-uninfected ( P > 0.50) groups, but the HIV-uninfected group had a higher prevalence of A1c >5.7% (33% vs. 20%, P = 0.024). We found a relatively strong correlation between A1c and FBG (r = 0.67). An A1c ≥6.5% had a poor sensitivity (46%, 95% CI 26-67%) but high specificity (98%, 95% CI 96-99%) for detecting diabetes. More work is needed to define an optimal A1c for screening diabetes in SSA.

Validation of the nonlaboratory-based Framingham cardiovascular disease risk assessment algorithm in the Atherosclerosis Risk in Communities dataset.

BACKGROUND: Nonlaboratory-based (non-LB) algorithms have been developed to facilitate absolute cardiovascular risk assessment in resource-constrained settings. The non-LB Framingham algorithm, which substitute BMI for lipids in laboratory-based Framingham, exhibits best performance among non-LB algorithms. However, its external validity has not been evaluated. AIM: To examine the validity of non-LB Framingham algorithm in Atherosclerosis Risk in Communities dataset, and contrast performance with the laboratory-based Framingham algorithm. METHODS: We developed Cox regression models including non-LB and laboratory-based Framingham covariates in Atherosclerosis Risk in Communities dataset. Discrimination was assessed via C-statistic, calibration via goodness-of-fit, and marginal discrimination value of BMI vis-à-vis lipids vis-à-vis waist-hip ratio via net reclassification improvement (NRI). Both models were compared via area under receiver operating characteristic. RESULTS: Among 11 601 participants (mean age 54 years, 55% women, 23% black), non-LB vs. laboratory-based Framingham performed as follows: C-statistic 0.75 vs. 0.76 among women and 0.67 vs. 0.68 among men; goodness-of-fit 14.2 vs. 10.5 among women and 25.8 vs. 21.8 among men. Overall area under receiver operating characteristic was 0.706 vs. 0.710, respectively, with no racial differences in discrimination or calibration. BMI and total cholesterol had no impact on NRI. Incremental predictive value of HDL was comparable with waist-hip ratio (category-less NRI = 0.34 vs. 0.31; categorical NRI = 0.06 vs. 0.05, P < 0.01). CONCLUSION: These results demonstrate the validity and limitations of the non-LB Framingham algorithm in a biracial cohort. Substituting BMI with a central adiposity metric such as waist-hip ratio or waist circumference could make the algorithm better or at par with the laboratory-based Framingham algorithm.