Strangers in a strange land: mapping household and neighbourhood associations with improved wellbeing outcomes in Accra, Ghana

Urban poverty is not limited to informal settlements, rather it extends throughout cities, with the poor and affluent often living in close proximity. Using a novel dataset derived from the full Ghanaian Census, we investigate how neighbourhood versus household socio-economic status (SES) relates to a set of household development outcomes (related to housing quality, energy, water and sanitation, and information technology) in Accra, Ghana. We then assess "stranger" households' outcomes within neighbourhoods: do poor households fare better in affluent neighbourhoods, and are affluent households negatively impacted by being in poor neighbourhoods? Through a simple generalized linear model we estimate the variance components associated with household and neighbourhood status for our outcome measures. Household SES is more closely associated with 13 of the 16 outcomes assessed compared to the neighbourhood average SES. Second, for 9 outcomes poor households in affluent areas fair better, and the affluent in poor areas are worse off. For two outcomes, poor households have worse outcomes in affluent areas, and the affluent have better outcomes in poor areas, on average. For three outcomes "stranger" households do worse in strange neighbourhoods. We discuss implications for mixed development and how to direct resources through households versus location-based targets.

Phenotyping urban built and natural environments with high-resolution satellite images and unsupervised deep learning

Cities in the developing world are expanding rapidly, and undergoing changes to their roads, buildings, vegetation, and other land use characteristics. Timely data are needed to ensure that urban change enhances health, wellbeing and sustainability. We present and evaluate a novel unsupervised deep clustering method to classify and characterise the complex and multidimensional built and natural environments of cities into interpretable clusters using high-resolution satellite images. We applied our approach to a high-resolution (0.3 m/pixel) satellite image of Accra, Ghana, one of the fastest growing cities in sub-Saharan Africa, and contextualised the results with demographic and environmental data that were not used for clustering. We show that clusters obtained solely from images capture distinct interpretable phenotypes of the urban natural (vegetation and water) and built (building count, size, density, and orientation; length and arrangement of roads) environment, and population, either as a unique defining characteristic (e.g., bodies of water or dense vegetation) or in combination (e.g., buildings surrounded by vegetation or sparsely populated areas intermixed with roads). Clusters that were based on a single defining characteristic were robust to the spatial scale of analysis and the choice of cluster number, whereas those based on a combination of characteristics changed based on scale and number of clusters. The results demonstrate that satellite data and unsupervised deep learning provide a cost-effective, interpretable and scalable approach for real-time tracking of sustainable urban development, especially where traditional environmental and demographic data are limited and infrequent.

Synthesizing the links between secure housing tenure and health for more equitable cities

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

Synthesizing the links between secure housing tenure and health for more equitable cities

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

Quantifying within-city inequalities in child mortality across neighbourhoods in Accra, Ghana: a Bayesian spatial analysis

OBJECTIVE

Countries in sub-Saharan Africa suffer the highest rates of child mortality worldwide. Urban areas tend to have lower mortality than rural areas, but these comparisons likely mask large within-city inequalities. We aimed to estimate rates of under-five mortality (U5M) at the neighbourhood level for Ghana's Greater Accra Metropolitan Area (GAMA) and measure the extent of intraurban inequalities.

METHODS

We accessed data on >700 000 women aged 25-49 years living in GAMA using the most recent Ghana census (2010). We summarised counts of child births and deaths by five-year age group of women and neighbourhood (n=406) and applied indirect demographic methods to convert the summaries to yearly probabilities of death before age five years. We fitted a Bayesian spatiotemporal model to the neighbourhood U5M probabilities to obtain estimates for the year 2010 and examined their correlations with indicators of neighbourhood living and socioeconomic conditions.

RESULTS

U5M varied almost five-fold across neighbourhoods in GAMA in 2010, ranging from 28 (95% credible interval (CrI) 8 to 63) to 138 (95% CrI 111 to 167) deaths per 1000 live births. U5M was highest in neighbourhoods of the central urban core and industrial areas, with an average of 95 deaths per 1000 live births across these neighbourhoods. Peri-urban neighbourhoods performed better, on average, but rates varied more across neighbourhoods compared with neighbourhoods in the central urban areas. U5M was negatively correlated with multiple indicators of improved living and socioeconomic conditions among peri-urban neighbourhoods. Among urban neighbourhoods, correlations with these factors were weaker or, in some cases, reversed, including with median household consumption and women's schooling.

CONCLUSION

Reducing child mortality in high-burden urban neighbourhoods in GAMA, where a substantial portion of the urban population resides, should be prioritised as part of continued efforts to meet the Sustainable Development Goal national target of less than 25 deaths per 1000 live births.

Time and space catch up with restoration programs that ignore ecosystem service trade-offs

In response to extreme societal consequences of ecosystem degradation and climate change, attention to ecological restoration is increasing globally. In China, investments in restoration exceeded USD 378.5 billion over the past decade. However, restoration programs are experiments that can cause marked unintended consequences, with trade-offs across space and time that have undergone little empirical examination. We quantified the long-term effects of large-scale afforestation for soil erosion and sandstorm prevention in semiarid China. We found that soil erosion was notably reduced by afforestation but surface runoff declined significantly, after a time lag of 18 years, limiting overall benefit. While forest area also increased, forest quality declined, interacting with reduced surface water runoff. Crucially, increased forest water consumption accelerated downstream groundwater depletion, thus intensifying conflicts over water use. The time lags and spatial trade-offs revealed by this case study provide critical lessons for large-scale restoration programs globally.

Participatory Modeling of Water Vulnerability in Remote Alaskan Households Using Causal Loop Diagrams

Despite perceptions of high water availability, adequate access to sufficient water resources remains a major challenge in Alaska. This paper uses a participatory modeling approach to investigate household water vulnerability in remote Alaska and to examine factors that affect water availability and water access. Specifically, the work asks: how do water policy stakeholders conceptualize the key processes that affect household water vulnerability in the context of rural Alaska? Fourteen water policy stakeholders participated in the modeling process, which included defining the problem of household water vulnerability and constructing individual causal loop diagrams (CLDs) that represent their conceptualization of household water vulnerability. Individual CLDs were subsequently combined and five sub-models emerged: environmental, economic, infrastructure, social, and health. The environmental and economic sub-models of the CLD are explored in depth. In the environmental sub-model, climate change and environmental barriers due to geography influence household water vulnerability. In the economic sub-model, four processes and one feedback loop affect household water vulnerability, including operations and maintenance funding, the strength of the rural Alaskan economy, and the impact of regulations. To overcome household water vulnerability and make households more resilient, stakeholders highlighted policy solutions under five themes: economics, social, regulatory, technological, and environmental.

Reimagining the potential of Earth observations for ecosystem service assessments

The benefits nature provides to people, called ecosystem services, are increasingly recognized and accounted for in assessments of infrastructure development, agricultural management, conservation prioritization, and sustainable sourcing. These assessments are often limited by data, however, a gap with tremendous potential to be filled through Earth observations (EO), which produce a variety of data across spatial and temporal extents and resolutions. Despite widespread recognition of this potential, in practice few ecosystem service studies use EO. Here, we identify challenges and opportunities to using EO in ecosystem service modeling and assessment. Some challenges are technical, related to data awareness, processing, and access. These challenges require systematic investment in model platforms and data management. Other challenges are more conceptual but still systemic; they are byproducts of the structure of existing ecosystem service models and addressing them requires scientific investment in solutions and tools applicable to a wide range of models and approaches. We also highlight new ways in which EO can be leveraged for ecosystem service assessments, identifying promising new areas of research. More widespread use of EO for ecosystem service assessment will only be achieved if all of these types of challenges are addressed. This will require non-traditional funding and partnering opportunities from private and public agencies to promote data exploration, sharing, and archiving. Investing in this integration will be reflected in better and more accurate ecosystem service assessments worldwide.

Soil-targeted interventions could alleviate locust and grasshopper pest pressure in West Africa

Agricultural land use has intended and unintended consequences for human livelihoods through feedbacks within coupled human and natural systems. In Senegal, West Africa, soils are a vital resource for livelihoods and food security in smallholder farming communities. In this study, we explored the connections among land use, soil conditions, plant nutrient content, and the abundance of several locust and grasshopper species. We worked in two rural farming villages in the Kaffrine region of Senegal. Oedaleus senegalensis was least abundant in groundnut areas where plant N was highest and abundance was negatively correlated with plant N across land use types. Overall, grasshoppers were most numerous in grazing and fallow areas. There was little variation in soil properties across land use types and soil organic matter (SOM) and inorganic soil N content were low throughout. SOM was positively correlated with soil inorganic N concentration, which in turn was positively correlated with plant N content. Of the management practices we surveyed, fallowing fields was important for soil N and SOM replenishment. These results corroborate other research indicating that land use, management practices, soil and plant nutrients, and insect herbivore abundance are mechanistically coupled. Although further research is needed, improving soil fertility could be used as an alternative to pesticides to keep locusts at bay and improve crop yields.

How do herders do well? Profitability potential of livestock grazing in Inner Mongolia, China, across ecosystem types

Livestock production has increased in Inner Mongolia, China, despite widespread documentation of grassland degradation. To begin investigating the relationship that produces these trends, we studied farm-level decisions of herder households. We estimated economic enterprise budgets for 15 counties in Inner Mongolia across five ecosystems in 2009 and 2014 by using household survey data. Six counties decreased livestock stocking rates and had improved profit over time. The remaining counties increased their stocking rates over the period studied and profit decreased for all but one county. Livestock operators who reported negative profit over the 5 years were located across ecosystem types and reported a large number of weather shocks that affected grassland availability. Removing the opportunity cost of land and labour from the economic enterprise budgets resulted in a positive profit for all counties, which may explain why herders continue to increase stocking rates with decreased grassland availability over time.

Nitrogen balance dynamics during 2000-2010 in the Yangtze River Basin croplands, with special reference to the relative contributions of cropland area and synthetic fertilizer N application rate changes

With the increases of cropland area and fertilizer nitrogen (N) application rate, general N balance characteristics in regional agroecosystems have been widely documented. However, few studies have quantitatively analyzed the drivers of spatial changes in the N budget. We constructed a mass balance model of the N budget at the soil surface using a database of county-level agricultural statistics to analyze N input, output, and proportional contribution of various factors to the overall N input changes in croplands during 2000–2010 in the Yangtze River Basin, the largest basin and the main agricultural production region in China. Over the period investigated, N input increased by 9%. Of this 87% was from fertilizer N input. In the upper and middle reaches of the basin, the increased synthetic fertilizer N application rate accounted for 84% and 76% of the N input increase, respectively, mainly due to increased N input in the cropland that previously had low synthetic fertilizer N application rate. In lower reaches of the basin, mainly due to urbanization, the decrease in cropland area and synthetic fertilizer N application rate nearly equally contributed to decreases in N input. Quantifying spatial N inputs can provide critical managerial information needed to optimize synthetic fertilizer N application rate and monitor the impacts of urbanization on agricultural production, helping to decrease agricultural environment risk and maintain sustainable agricultural production in different areas.

Conservation vs. livelihoods: spatial management of non-timber forest product harvests in a two-dimensional model

Areas of high biodiversity often coincide with communities living in extreme poverty. As a livelihood support, these communities often harvest wild products from the environment. But harvest activities can have negative impacts on fragile and globally important ecosystems. This paper examines trade-offs in ecological protection and community welfare from the harvest of wild products. With a novel model and empirical evidence, I show that management of harvest activity does not always resolve these trade-offs. In a model of continuous harvests in a two-dimensional landscape, managed harvest activity improves welfare, but is uniformly bad for other ecosystem services that are sensitive to the presence (as opposed to the intensity) of human activity. Empirical results from a unique dataset of mushroom harvesters in Yunnan, China suggest more experienced, poorer, and more vulnerable individuals tend to rely on more distant harvests. Thus, policies that limit the extent of forest travel, such as protected areas, may protect fragile ecosystems but can have a disproportionately negative effect on those most vulnerable.

Meta-studies in land use science: Current coverage and prospects

Land use science has traditionally used case-study approaches for in-depth investigation of land use change processes and impacts. Meta-studies synthesize findings across case-study evidence to identify general patterns. In this paper, we provide a review of meta-studies in land use science. Various meta-studies have been conducted, which synthesize deforestation and agricultural land use change processes, while other important changes, such as urbanization, wetland conversion, and grassland dynamics have hardly been addressed. Meta-studies of land use change impacts focus mostly on biodiversity and biogeochemical cycles, while meta-studies of socioeconomic consequences are rare. Land use change processes and land use change impacts are generally addressed in isolation, while only few studies considered trajectories of drivers through changes to their impacts and their potential feedbacks. We provide a conceptual framework for linking meta-studies of land use change processes and impacts for the analysis of coupled human-environmental systems. Moreover, we provide suggestions for combining meta-studies of different land use change processes to develop a more integrated theory of land use change, and for combining meta-studies of land use change impacts to identify tradeoffs between different impacts. Land use science can benefit from an improved conceptualization of land use change processes and their impacts, and from new methods that combine meta-study findings to advance our understanding of human-environmental systems.

Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community

Despite reports of high prevalence of human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) among the transgender community, very little prevention education has targeted this population. To fill this gap, we developed and evaluated a transgender-specific intervention, All Gender Health, which incorporates prevention strategies into comprehensive sexuality education. Transgender participants (N=181) attended the two-day seminar in community-based venues. The curriculum was delivered via lectures, panel discussions, videos, music, exercises and small group discussions. Attitudes toward condom use, safer sex self-efficacy and sexual risk behaviour were evaluated before participation in the intervention (pre-test), immediately after participation (post-test) and at three-month follow-up. Compared to pre-test values, significant improvements were seen in attitudes toward condom use and in safer sex self-efficacy at post-test, and in attitudes toward condom use, increased monogamy and decreased sexual risk behaviour at three-month follow-up. Pre-test data identified unprotected anal, vaginal and oral sex as the most commonly reported risk behaviours. Many respondents also indicated problems with social discrimination, depression, suicidal ideation and sexual functioning. Future interventions should address these risk co-factors. Alternative interventions need to be developed to target those who, as a result of social marginalization, are less likely to be reached with an intensive seminar-based intervention.

Improving safer sex measures through the inclusion of relationship and partner characteristics

This article describes the development of a safer sex algorithm, which considers the characteristics of a woman's relationship and the HIV risk profile of herself and her primary partner. A sample of 306 low-income, predominantly African American women was recruited to participate in a study of the effectiveness of a sexual health seminar. These women were interviewed three times, at one month prior to seminar administration, three months after the seminar and again nine months after the seminar. Data from these women indicate that using an algorithm that considers the probability of HIV transmission between partners decreases the measured prevalence of unsafe sex in this population by about 17% and lowers the estimate of the average number of unsafe incidents by about four incidents in three months. The algorithm results in measures with adequate levels of temporal stability, which are similar to the more commonly used measure, vaginal or anal intercourse without a condom.

Meta-analysis of the effectiveness of HIV prevention interventions for women

The present study is a meta-analysis of the effectiveness of HIV prevention interventions for women in the USA. Twenty-four articles from 1989-1997 were included. We evaluated five ethnic groupings (All Ethnicities Combined, African-American, White, Hispanic and a Mixed Ethnicity group) over four time periods (post-test, less than two months after the intervention, 2-3 months after the intervention and 6-24 months after the intervention) on three HIV-related sexuality outcome variables (HIV/AIDS knowledge, self-efficacy and sexual risk reduction behaviour). The HIV interventions appear effective at improving knowledge about HIV/AIDS and increasing sexual risk reduction behaviours for all ethnicities examined at all follow-up periods, with one exception. The findings for self-efficacy are less consistent. The interventions were less consistently effective for African-American women, for whom significant improvements in feelings of self-efficacy were only seen six months or longer after the intervention. The present analysis elucidates ethnic differences which may have previously been obscured while demonstrating convincingly that HIV interventions are generally effective for women of many different ethnicities.

Physician confidence and interest in learning more about common geriatric topics: a needs assessment

OBJECTIVE

To assess physicians' confidence in and interest in learning more about 18 specific geriatric topics.

DESIGN

Written survey.

SETTING

Annual meetings of the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP).

PARTICIPANTS

Seven hundred and fifty-eight physicians (547 ACP members, 211 AAFP members).

MEASUREMENTS

For each topic, participants rated their confidence in performance, their peers' need for education, and their interest in learning more, using a five-point Likert scale.

RESULTS

Survey participants were on average 16 years out of medical school and 61% were in a community primary care practice that included many geriatric patients on a primarily fee-for-service basis. High levels of interest in learning more about dementia, functional assessment, urinary incontinence, and sensory impairment were found. A substantial correlation (r =.44, P <.0001) between the proportion of seniors reported in the physicians' practice and confidence in performance in the areas surveyed was identified.

CONCLUSIONS

These findings provide useful information on the physician-learner's perception of needs, which is important in the design of effective continuing education efforts in geriatrics.

Fat phobia scale revisited: the short form

OBJECTIVE

To develop a shortened form of the original 50-item fat phobia scale.

METHOD

The first factor from the original fat phobia scale-undisciplined, inactive and unappealing-was identified as a potential short form of the scale. A new sample of 255 people completed the original 50-item scale. The reliability of a shortened 14-item version of the scale was tested and compared to that of the full scale using both the new sample and the original sample of 1135 study participants.

RESULTS

The fat phobia scale-short form demonstrated excellent reliability in both samples and was strongly correlated with the 50-item scale. Mean and 90th percentile scores are given for both the long and short versions of the scale.

CONCLUSION

The shortened fat phobia scale is expected to increase the utility of the measure in a diverse array of research and clinical settings. Future research should focus on developing scale norms for the general population and conducting research on fat phobia in males and among different ethnic groups.

Criterion-related validity of the Marital Disaffection Scale as a measure of marital estrangement

The Marital Disaffection Scale was administered, along with measures of positive feelings towards spouse, problem-drinking behavior of spouse, workaholic behavior of spouse, and marital status, to 323 female members of the American Counseling Association. Scores on the Marital Disaffection Scale showed significant inverse correlations (r = -.94) with positive feelings towards spouse and (rpb = -.63) with marital status. Scores on the Marital Disaffection Scale showed significant positive relationships (r = .36) with spouse's problem drinking behavior and (r = .48) with workaholic behavior of spouse. The results support the use of the Marital Disaffection Scale as a measure of emotional estrangement in marriage.

Postgraduate educational opportunities in the military services

The three branches of the service provide advanced training to about 450 dentists each year. Approximately one-third of these positions are in post-doctoral general dentistry and the remainder in specialties, distributed as needed by the various services.

Cognitive predictors of resistiveness in dementia patients

Resistiveness to physical care among patients with dementia is a common and burdensome problem. Forty-nine nursing home residents with dementia were administered the Mini-Mental State Exam (MMSE) and the Royall Executive Interview (EXIT), a specific test of frontal-subcortical function. Nurses rated resistiveness on every shift for 3 days. Correlation with resistiveness ratings was stronger for the EXIT (r=0. 73) than for the MMSE (r=-0. 46); logistic modeling found the EXIT to be a strong independent predictor of resistiveness. Executive dysfunction as measured by the EXIT is a major determinant of resistiveness to care in long-term care residents with dementia, possibly as a result of such patients' tendency toward inertia.

Assessing the offspring of workaholic parents: the Children of Workaholics Screening Test

This study reports initial stages in the development of a self-report instrument that measures offsprings' mental disposition toward their parents' work habits. In an initial sitting, a battery of tests was administered to 207 young adults to assess the reliability and validity of the Children of Workaholics Screening Test. After a 2-wk. interval, the test was administered again. Test-retest reliability, split-half reliability, and concurrent validity are reported. The findings provide strong support for the utility of the Children of Workaholics Screening Test for assessing the offspring of workaholic parents.

Factors associated with the prevalence of myopia in 6-year-olds

PURPOSE

To describe the frequency of and risk factors associated with myopia in grade one children.

METHODS

Refractive error was measured by static retinoscopy, without cycloplegia, for 10,616 children in the first year of a province-wide vision-screening program. Information on factors that might be associated with myopia was collected from parents or guardians by self-administered questionnaires distributed before the vision screening. These factors were evaluated by a case-control method.

RESULTS

The prevalence of myopia, greater than -0.25 D, was 6%. The estimated relative risk of myopia was increased significantly among children whose birth weight was <2500 g and whose mothers had a history of early spectacle use.

CONCLUSIONS

Results suggest that the prevalence of myopia in 6-year-old children is associated with both hereditary and nonhereditary factors. In accord with prior work, the results argue that low birth weight has a permanent influence upon eye development.

Therapeutic uses of sexually explicit materials in the United States and the Czech and Slovak Republics: a qualitative study

This study investigates the reflections of 279 U.S. and Czech and Slovak mental health and health professionals about their use of sexually explicit materials. Professionals were 2.6 times as likely to cite specific instances when their use of sexually explicit materials was useful with their clients and students than they were to cite instances when such materials were not useful. In addition, no significant differences were observed between the ways in which U.S. and Czech and Slovak mental health and health professionals evaluated these materials. The article presents several suggestions for the judicious and efficacious use of sexually explicit materials in therapy or in the classroom in either Western or Central European settings.

The Work Addiction Risk Test: development of a tentative measure of workaholism

The development and analyses of the psychometric characteristics of a tentative self-report measure of work addiction are reported. A total of 363 college students completed a battery of tests including the Work Addiction Risk Test. Internal consistency of the scores was .88. Also, these scores were compared with those on the Type A Self-rating Scale and the Jenkins Activity Survey, which give self-reports of Type A behavior and the State-Trait Anxiety Inventory. That scores on the work addiction risk test were reliable and showed concurrent validity supported psychometric utility for research and clinical practice.

Diabetic ketoacidosis associated with cocaine use

BACKGROUND

Multiple risk factors for diabetic ketoacidosis (DKA) have been described, including omission of insulin therapy and clinical conditions known to increase counterregulatory hormones. Recently, substance abuse has been identified in patients with DKA. We observed many cases of DKA in cocaine users, although the association between cocaine use and DKA has not been well described in the medical literature.

METHODS

We performed a retrospective case-control study of admissions for DKA in cocaine users and non-user controls in an urban teaching hospital from January 1, 1985, to December 31, 1994.

RESULTS

We identified 720 adult admissions for DKA. Twenty-seven cocaine users accounted for 102 admissions (14% of all DKA admissions). The users were compared with 85 nonuser controls who had 154 DKA admissions. Cocaine users had more admissions for DKA (mean, 3.78 vs 1.81; P = .03). Cocaine users were less likely than controls to have an intercurrent illness identified as a precipitating factor for DKA (14.7% vs 33.1%; P<.001) and were more likely to have missed taking insulin prior to admission (45.1% vs 24.7%; P<.001). Although cocaine users had higher serum glucose levels on admission (32.9 mmol/L [593.4 mg/dL] vs 29.5 mmol/L [531.1 mg/dL]; P =.03), no differences in intensity of illness or treatment outcome were detected.

CONCLUSIONS

In this preliminary study, cocaine use was found in a significant number of adults admitted with DKA and was associated with more frequent omission of insulin therapy and the absence of precipitating systemic illness. Either because of its association with insulin therapy omission or its effects on counterregulatory hormones, cocaine use should be considered a risk factor for DKA, particularly in patients with multiple admissions.

Transgender HIV prevention: a qualitative needs assessment

Although clinical experience and preliminary research suggest that some transgender people are at significant risk for HIV, this stigmatized group has so far been largely ignored in HIV prevention. As part of the development of HIV prevention education targeting the transgender population, focus groups of selected transgender individuals assessed their HIV risks and prevention needs. Data were gathered in the following four areas: (1) the impact of HIV/AIDS on transgender persons; (2) risk factors; (3) information and services needed; and (4) recruitment strategies. Findings indicated that HIV/AIDS compounds stigmatization related to transgender identity, interferes with sexual experimentation during the transgender 'coming out' process, and may interfere with obtaining sex reassignment. Identified transgender-specific risk factors include: sexual identity conflict, shame and isolation, secrecy, search for affirmation, compulsive sexual behaviour, prostitution, and sharing needles while injecting hormones. Community involvement, peer education and affirmation of transgender identity were stressed as integral components of a successful intervention. Education of health professionals about transgender identity and sexuality and support groups for transgender people with HIV/AIDS are urgently needed.

Review of Medicare's proposed hospice eligibility criteria for select noncancer patients

Recent events have challenged our health system to increase access to and provide high quality care for patients near the end of life. Simultaneously, Medicare is developing review policies to determine eligibility for hospice patients with select noncancer diagnoses. The purpose of this study was to determine whether the proposed policies met one of their chief goals: accurate identification of patients with a less-than-six-months prognosis. Only 35 percent of 104 patients who died within six months of admission to the hospice used for this study, LifePath Hospice, met the Medicare proposed criteria for hospice eligibility. The median and mean survival time of the sample was 14 and 30 days respectively. Based on this review, it is recommended that Medicare alter their proposed review policies and not limit access to hospice eligible patients who desire and are in need of such services.

Diagnosis of irreversible dementia: how extensive the evaluation?

Recommendations for managing the patient with irreversible dementia can be organized according to the results of the initial evaluation. The patient may have normal mental status and normal functional assessment, abnormal mental status and abnormal functional assessment, or mixed results (one normal, one abnormal). The extent of further investigations usually depends on initial clinical findings and on patient and/or family preferences. MRI imaging may be useful prior to referral if greater specificity in diagnosis is desired. Referral is suggested for illnesses of short duration, atypical features, or when the patient and family require precision in diagnostic labeling.

Guideline for initial evaluation of the patient with memory loss

A practical and useful guideline for early identification of Alzheimer's disease and related dementias has been developed by the Agency for Health Care Policy and Research. By using the initial evaluation process described in this guideline, primary care physicians can identify and treat many "reversible" causes of memory problems, such as depression, delirium, and co-morbid medical conditions. The treatable causes of dementia may be structural, metabolic, toxic, infectious, nutritional, psychiatric, or drug-related. Initial evaluation includes patient history, physical examination, mental status testing, functional assessment, and some laboratory tests. Information from an informed family member can be very helpful in this process.

Occupational exposure to optical radiation and the ocular health status of glassblowers

The occupational radiation exposure levels and the ocular health status of a sample of glassblowers in southern Ontario were evaluated. The form of ocular protection was also assessed. Measurements of radiant emissions from different molten glass materials were carried out. A total of six glassblowing installations, 15 glassblowers and 42 non-glassblowers participated in the study. The spectral transmittances of samples of the protective lenses were obtained. Tonometry, biomicroscopy, ophthalmoscopy, pachometry, Schirmer tear test, endothelial photography were completed on all the volunteering subjects. The glassblowers' ocular findings were compared to those of non-glassblowers. No indication of cataract was observed among this group of glassblowers. Although, a preponderance of grade 2 polymegethism among the glassblowers (47% compared to 11% in non-glassblowers) was found, there was no significant difference in their ocular health. Variation in the corneal irradiance from occupational exposure was obtained, and in addition, the use of protective lenses was found to be inappropriate. In order to prevent against any long-term chronic pathologic effect, the use of appropriate ocular protection is advised.

Risk of addiction to work and family functioning

A total of 107 self-identified workaholics from across the United States and Canada responded to a set of inventories assessing their scores on the Work Addiction Risk Test and the correlations with current family functioning. Individuals in the High-risk group, compared to those in the Low- and Medium-groups, were significantly more likely to perceive their current families as having less effective problem-solving ability, worse communication, less clearly established family roles, fewer affective responses, less affective involvement, and lower general family functioning.

Attitudes of U.S. and Czech/Slovak mental health and health professionals toward five types of sexually explicit materials

Mental health and health professionals' attitudes toward sexually explicit materials in the U.S. and Czech/Slovak Republics were investigated. An instrument measuring attitudes toward educational, soft-core, hard-core, violence, and bizarre/paraphiliac sexually explicit materials was administered to sexologists, psychologist/counselors, and medical professionals. These professionals were attending conferences in the U.S. and the Czech/Slovak Republics between November 1992 and September 1993. Mental health and health professionals had the most favorable attitudes toward educational sexually explicit materials followed by soft-core and hard-core materials, respectively. They had unfavorable attitudes toward violent and bizarre/paraphiliac sexually explicit materials, with particularly negative attitudes toward violent materials. Analysis of covariance showed that strength of religious conviction was a significant covariate; thus professionals with stronger religious conviction had more negative attitudes toward all five types of sexually explicit materials. When controlling for strength of religious conviction: (i) sexologists had more positive attitudes toward most types of sexually explicit materials; (ii) Czech professionals generally had more positive attitudes toward such materials than their U.S. counterparts; and (iii) there were few differences between female and male professionals in their reported attitudes. While previous literature has reported gender differences in attitudes toward sexually explicit materials, findings from this study suggest that this effect may be due to differences in religiosity among women and men, namely, that women tend to be more religious.

Concurrent validity of the Beck Depression Inventory as a measure of depression

The Beck Depression Inventory was administered, along with measures of anxiety, locus of control, and self-concept, to 211 undergraduates at a major southern institution to test for concurrent validity. Correlations of scores on Beck's scale with other scores provide additional support for Beck's scale as a valid measure of depression.

Concurrent validity of the Work Addiction Risk Test as a measure of workaholism

The Work Addiction Risk Test was administered, with a measure of anxiety and two measures of Type A behavior, to 363 undergraduates at a major southern institution to test for concurrent validity. Correlations of scores on the Work Addiction Risk Test with other scores support the scale as a valid measure of workaholism.

Life values, resuscitation preferences, and the applicability of living wills in an older population

OBJECTIVES

To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills.

DESIGN

Individual structured interviews.

SETTING

An independent retirement community.

PARTICIPANTS

One hundred thirty-two subjects older than 63 years of age.

MEASUREMENTS

Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements.

RESULTS

The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will.

CONCLUSION

Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.

Cost-effectiveness of hospice care

Is hospice cost-effective? What is perfectly clear is that hospice care overall provides different care than conventional care for the dying. There is much more home care, aimed at goals of comfort, dignity, and remaining at home, and that care is distributed over longer periods of time. There is less hospital care and less anticancer therapy. Nonhospice oncologic care provides more hospital services, particularly in the last month of life, and more effort to directly attack the malignant disease. There will always be those individuals whose goals and medical condition at a particular time make one type of care the best choice for that person. Current research strongly supports hospice care as cost-saving in the last month of life. The overall effect of hospice care on costs appears to be weakly positive. This is despite the fact that hospice benefits under Medicare include absence of co-payment, medications for the primary condition, and substantially more supportive services, which represent extra value and decreased out-of-pocket expenses to the consumer. A factor strongly favoring the development of cost-effective programs is the fact that most hospices began and developed as capitated systems of care. Thus the benefits derived from providers working with patients to control costs have accrued over time. The not-for-profit structures led savings to be put back into patient care, allowing more help for families and patients. An unresolved bias of available research is the question of the extent to which hospice patients are self-selected at the time of entry for their low interest in intensive and expensive services. The most positive estimates of cost-savings in hospice have required case-mix or time-of-entry adjustments to demonstrate savings. There is little support for cost-savings in the raw data comparing total costs in hospice and conventional care groups. However, there is also no evidence that hospice care adds to costs of care for the dying. Differences in outcomes between hospice- and conventional-care have been modest. Satisfaction with care has often been higher in hospice care, but care giver burden may also be higher. Other outcome measures have been inconsistently affected. The task of measuring differences is a difficult one. Hospice patients themselves are largely unavailable for measurement during the most critical periods of care, and proxy measures of benefit are necessary. Families also tend to be grateful (or critical) around the death of a loved one; this is related to complex family relationships and emotions not likely to be influenced by any health care program. It should also be noted that the task of measuring the success of hospice care has largely used measures originally developed for understanding the impact of conventional oncologic care. The tools for understanding the effects of spiritual counseling or homemaker assistance are much less well developed. The initial goals of the Medicare hospice benefit appear to have been met: a choice is available that responds to the needs and concerns of many dying people and their families, at no additional cost to the taxpayer. In addition, millions of families have received the benefit of the lower out-of-pocket costs for health services and medications. They have benefited from the broader definition of health which made simple, continuous support services such as homemaking and personal care available at no charge. The question of hospice cost-effectiveness would seem to be a question of the past. Other questions offer even more substantial challenges to continuing hospice care as it is now offered and into the future. There are no data to allow a critique of the current structure of hospice services, or to support the link between individual components of service and outcomes. This leaves the hospice concept open to considerable manipulation.(ABSTRACT TRUNCATED)

Death by destruction of will. Lest we forget

This report describes an unexplained death following the collapse of will caused by resisted mechanical restraint in a 93-year-old woman with dementia. Clinical and experimental evidence is cited supporting resisted restraint as a significant noxious stimulus that can be linked to sudden death and immune dysfunction. This woman's story serves to remind us of the critical link between mind and body, and of the mortal consequences possible when we forget.

Measuring workaholism: content validity of the Work Addiction Risk Test

A total of 20 psychotherapists, randomly selected from a state list, critically examined the 25 items on the Work Addiction Risk Test for content validity. Subjects were asked to identify 25 items from a list of 35 which most accurately measured work addiction. Selected test items have generally high content validity for the domain of work addiction.